Sayonara kiddos

I am all finished with my pediatric rotation and all finished with my last winter semester ever! Overall peds went very well. I had a lot of uncertainties going into this rotation. I wasn't sure I was going to like it at first because of the drastic change from trauma to that but the kiddos grew on me a little more each week. Doing the rotation in my home town was also something I was unsure of. It was odd running into people that I went to high school with and played on sports teams with. I would like to know what some of them were thinking when I walked into the room to examine their child. Then again, judging by the looks on some of thier faces maybe it's best if I don't know. I was unsure of how working with my uncle was going to go too. Working with my uncle turned out to be a good decision. I learned a lot from him but we also had fun. It was nice to not be intimidated for once. He is a fantastic pediatrician and I can see why everyone wants him to treat their children.

There is one thing that keeps sticking in my mind about this rotation. While here I have seen that there is a real need for more medical practioners. As students we have all had the "underserved" lecture and most of us listen but then don't really think about it again. Nurses and patients kept asking me if I was going to be coming back to the area to practice. They all really wanted me to come back because I am familiar with the people and they need more practioners. I do not plan to come back to the area to practice, at least not right away. I really feel like scum for that. There is a true need and I am knowingly walking away. I do not see myself being content doing family practice in a small town though. Perhaps someday when I have a family and am looking for something more layed back I'll consider it.

So to sum up the last six weeks I'd say that I have learned a great deal of pediatric medicine, I have learned that I absolutely adore newborns, and I have gained a new found respect for the people of this area and for rural medicine in general.

In case you are wondering why there is a scenic lake picture on here that's Raystown Lake, the lake in my hometown.

I have learned something on this rotation that I doubt I will be seeing or doing on any other rotation, circumcision. Circumcising or as we affectionately call it in the office "whacking wienies" is actually a pretty cool procedure to see. I can say this because I am a female. I highly doubt there is a man alive that could watch this without wincing. The instruments used for the procedure even have cool names like the Gomco, "helmet" (bet you can't guess where that goes), kellys, probe, and the circumstraint. I think the "helmet" might actually be called a bell but we refer to it as the helmet because it's more fun. The whole procedure takes around 20 minutes and is pretty much blood free which is kind of amazing considering you are amputating skin. Most of the babies tolerate it pretty well too. They are given a few drops of a sugar based liquid then a pacifier is stuck in their mouth. The doctor I am with uses a local anesthetic as well. That sugar must be some good stuff because the babies don't seem to notice you sticking a needle into the bottom of their little peenies. A funny side note: I noticed that when we inject the lidocane it of course causes the base to swell making it look a lot like a tiny little elephant trunk.

The success of the procedure is dependent on correctly fitting tools and the doctor's ability to achieve hemostasis. This is done with hemostats and the Gomco clamp. Patience and precision are also key. I was watching the doctor do one the other day and I realized just how important it is that he get this perfect. He can't leave even a millimeter of skin because that millimeter of skin will grow with the rest of him. This little guy has to carry that penis around with him for the rest of his life! You can't have one that looks like the result of a drunken lovefest between a turtle, an elephant, and a grub. Some girl will take one look at that and run the other way! The doctor I'm with is very good at them so rest assured Huntingdon county you will remain well populated in the future.

The after care is pretty easy as well. You just put Vaseline on it for a few days until it heals. End of story. The procedure seems to be well tolerated by the little ones and makes taking care of them a little easier on the parents. Even after watching this I would still want my future sons to have it done.

"Babies are such a nice way to start people" -Don Herrold

So far my favorite part of peds is the babies. I'm talking the really young little babies, 4 weeks and under. In the practice that I am in we see them within 24 hours of birth and then again at 1-2 weeks and again at 4 weeks. So I've been getting to see a lot of little ones. When we see them in the hospital within 24 hours they are brand spankin' new. It makes getting up an hour and a half early worth it. I love almost everything about them at this age. I love how they are still always warm when you hold them. I love the fresh clean baby smell. I love their onsies and tiny socks. I love the way they get raging mad and scream at you when you undress them and examine them with your freezing cold hands. I love playing with their reflexes. I love how their eyes look so fresh and shiny when they open them. I love their soft baby hair. I love the little grunting noises they make. I love to watch them as they discover new things, like their hand. This list could keep going and going but I'm sure I've already lost over half of your interest already so I'll stop. I haven't seen any super sick newborns yet. I saw one with Tetralogy of Fallot but she was stable and doing well for now. If I were in a different setting like a NICU I might change my mind. I can't imagine how difficult that would be.

Like OB, this specialty is making me excited at the prospect of having little babies in the house. I'm not in any position to be having children right now so someone in my family needs to have a baby soon so I can get this out of my system!!!! Sorry for the lack of medical things in this post. Next time I'll try to find an interesting case instead of just rambling on and on about my love for newborns. I promise!

Kids kids kids

First let me apologize for not updating this for a week and a half. A lot has happened since I last posted, I moved back home and started my next rotation. I am now doing pediatrics in my hometown with my uncle at his office. It has been an interesting transition. I haven't lived at home for this long in 9 years. I'm still getting used to the daily phone calls asking what time I'm coming home and the occasional visit from our golden retriever in the middle of the night but overall it's going well. I especially like coming home to home cooked meals everyday and parking in a garage!

Going from a level one trauma center to outpatient pediatrics is quite the adjustment as well. In fact I don't think you can compare them in any way. It's a welcome change of pace though. Working with my uncle is very different too. For once I'm not intimidated out of my mind. That may sound bad but I mean it in a positive kind of way. I am still learning something everyday and being challenged. Examining children is completely different from examining an adult. We take things for granted with adults. Adults aren't terrified of a simple thing like a stethescope, well the "normal" ones aren't anyways. With an adult you just jump right in and do the exam, end of story. With little kids you have to explain everything you're going to do and let them touch everything first to prove to them it doesn't hurt. You have to earn their trust. You also have to earn the parents trust. All this has to be done in under 25 minutes! Talk about a challenge. I've only been doing peds for two weeks but I have found that these 5 things are necessary to successfully exam a kid:

5. A friendly face
4. A knowledge of current cartoons
3. A plethora of different noises and voices
2. A love for children
1. PATIENCE PATIENCE PATIENCE

I'm sure this list will grow weekly and I am looking forward to figuring out all of the secret little tricks of pediatrics.

I did it!!!! I made it through six weeks of trauma surgery at Hershey! Looking back on the whole thing I cannot believe I made it. Even falling asleep at night was difficult because I knew what I was going to have to face the next day- a butt kicking beyond anything I had experienced. There was no real way to prepare for the next day. You never knew what kind of traumas would roll through the doors. And you never knew what random topic you were going to be quizzed incessantly on that day. And when I say quiz I don't just mean "asked a question and if you don't know the answer big deal just look it up". I mean if you don't know the answer that's license to get in your face and rapid fire more and more questions until you have been reduced to a shapeless blob of pond scum. Some days by the time they were done with me I didn't even know my own name. Strangely this form of so called teaching actually worked for me. I think it worked because I was absolutely terrified of the humiliation that came from not knowing the answers.

The traumas themselves were challenging as well. From a medical standpoint it wasn't too bad because you just follow a specific algorithm that has been beat into your brain. The difficultly arose when you let your mind wonder from it's preprogrammed path to allowing it to process what exactly is going on from the human standpoint. In other words I got into trouble when I let myself feel. I only did trauma for six weeks so I never developed the ability to be unaffected by the events that had just unfolded in front of me. Many of the trauma attendings, PAs, and nurses have developed this. I don't think I ever want to get to the point where the loss of a life is routine. During my time at Hershey I saw at least a dozen level one traumas and a whole lot more level twos. There are three that stick out in my mind. I remember everything about them; the smells, sounds, injuries, and outcomes. I even remember the feeling after it's all over. It didn't matter what time of the day the trauma came in. When they were bad I always walked away in a state of numbness. I walked through the remainder of the day just going through the motions. I was afraid to allow myself to process the trauma in it's entirety until I was home in the comfort of my room and usually talking it out on the phone with a friend.

It may sound like it but I don't regret doing trauma surgery. I have come out on the other side a stronger person with tougher skin. I've learned how to take a beating and still hold my head up. I've matured as a PA was well. I feel more in control now in situations that seem out of control than I ever before. And finally I've learned that you can do well in any situation if you are willing to work hard enough for it. The best things in life are the things you sacrifice for.

Tragedy Strikes Again

Friday started out like any other day. At 6am I'm checking in on my assigned patient followed by signout at 6:30 and case studies at 7:30. We were just finishing up our case studies when the trauma pagers went off. It said "Level 1 trauma. Response STAT. Multiple adult and pediatric traumas." This was the first time I had seen a page like this. The most I've ever seen at once was 2. As usual we all stopped everything and ran downstairs to the ER. We got there and learned that there was a car accident and five teenagers were traumatically injured. All of these kids were in the same car and were on there way to school when they collided head on with another driver. Four of the five victims were unconscious and had to be extricated from the car. They were being flown in. A trauma of this nature required that every ATLS trained person in the entire hospital respond. I would guesstimate that around 50 people were involved directly in these traumas. It sounds like complete chaos but it went amazingly smooth. I was super impressed with how well orchestrated everything was. Every room had someone in charge and also had someone responsible for communicating with the other rooms about who's patient was the sickest and needed CT scanned first or the first available OR, or needed the massive transfusion protocol activated. I apparently drew the short straw because I ended up in the room with the sickest kid. He had major head, chest, abdominal, and orthopedic trauma. I was in the middle of this trauma when a nurse yelled that I was being paged to the OR by one of my attendings. I stopped everything I was doing and passed off my responsibilities to someone else and bolted upstairs to the OR.

I walked into the OR and the attending had already opened up and told me he needed another set of hands and to go scrub in. At this point I still had no idea what was going on because as far as I new this doctor was running a trauma two doors down from the one I just left. I got all scrubbed and joined the doctors at the table. Here the patient has was operating on was the driver of the car in the major accident. He required IMMEDIATE surgery to save his life. The boy had demolished his spleen among other intrabdominal structures and was actively bleeding out. I will spare you all the gory details of the procedure but let's just say it took around 3 1/2 hours to do what needed to be done. I'm happy to report that we were able to stop the bleeding and do adequate damage control to save his life. I haven't heard anything since I left the hospital Friday so I'm not sure of his current status.

This was the first time I had ever been paged to the OR to assist in a life saving operation so I was feeling pretty good about myself. However like most good trauma related feelings this was short lived. Once the urgency was over and things had stabilized the reality of what just happened set in. This was a 16 year old kid, he has a sibling in the OR a few doors down undergoing a similar operation. This family was just turned completely upside down in a short second. In fact four families were turned upside down. When I go into the hospital tomorrow I'm going to have to face these families. That is perhaps the hardest part, seeing the look of despair and sadness on the parents faces. As a student I usually do not have to talk to the family but I still have to be in the room when the doctor does. Hopefully tomorrow the questions that the families ask will have positive answers. I'm going to keep the attitude that they are kids and they bounce back quickly! Only three more days of trauma, then it's off to take care of kiddos who are not teetering on life's edge.

*the picture at the top is a grade 5 splenic laceration, one of the injuries we were repairing

Only by the grace of God

Yesterday was a busy day in the trauma bay. We had four between 7 and 12 alone. There was one trauma that really stood out to me more than all the others. The patch we received said that it was a 19 y/o female involved in a motor vehicle accident, tractor trailer vs Mitsubishi galant. They said she was merging into traffic and merged directly under the trailer of a truck!! We did not receive much information about the status of the patient except that she was self extricated. She came into the trauma bay in the usual way, on a stretcher on a spine board with a c-collar on so you couldn't really tell how serious her injuries were at first look. Once we got her unloaded and began examining her it became apparent that her only injury was a laceration on her forehead and another on her chin. We took her to CT where it was confirmed that she had ZERO injuries!! While she was being CT'd one of the paramedics on scene showed me the pictures of the accident. The front drivers side of the car was completely caved in. There was no cab anymore. The picture I uploaded in an actual picture from the scene. It doesn't really do it justice though. The pictures the paramedic had looked a lot worse because he was right up on the other side of the truck. According to the driver of the truck the car became stuck under the trailer and was drug a mile before he was able to completely stop. The car had caught on fire as well. Too look at the accident you would never think anyone would come out of that alive let alone unscathed. We were talking to the girl later and found that she was not belted and there were no air bags deployed either. This story was becoming more and more unbelievable. She told us that she saw what was coming and dove over across the front seats trying to make herself as flat as possible. This move is what ended up saving her life. I've seen several car accident victims die in the last four weeks from accidents much more minor than this one. I'm sure she walked away from this with a new appreciation for life. I know I did. I guess it goes to show that it's not your time until it's your time. (Profound I know, haha)

I'm Going to Need Counseling After this One

Today I experienced yet another level one trauma. This one was equally as terrible as the very first one I ever saw but in a different way. It was a 40 year old male in a car accident, he was t-boned. He came into the trauma bay making a gurgling sound and was not responsive. He had femoral pulses on arrival. We intubated him almost immediately. About three minutes into the trauma his vitals started to tank, we lost his pulses and his blood pressure. We activated the code protocol. At this point the attending decided a thoracotomy was this man's best chance for survival. For those of you who don't know what a thoracotomy is it's when they cut open a person's chest paralell to the ribs and spread the ribs to allow access to the heart. A procedure of this nature is typically done in the OR but today he did it in the middle of the trauma bay. As soon as he cut open the chest wall buckets of blood came spewing out all over the floor and all over everyone within five feet of the patient. The doctor then cut open the pericardial sack which contains the heart. As soon as that was open it blood came spurting out of that. The trajectory of the blood was similar to that of water coming out of a hose when you put your finger part way over the end of the nozzle. The doctor then found a hole the size of a nickle in this mans left ventricle. His heart was literally pumping all of his blood out of his body. The surgeon threw a few sutures in the hole to plug it as best he could. It was too late though. Even the internal paddles, cardiac massage, and internal compressions wouldnt restart it. He called it...

Once it was called the room cleared out as quickly as it had filled. There were only 10 of us left. The doctor called for me to come over to him and the patient and had me manually "search" through his thoracic cavity and identify all major organs and any injuries to those organs. It sounds gross but it was a unique learning experience that very few people get. He then said that I was going to do one more thing and it was something that I would never forget. He told me to sew the patient up completely and make him presentable for his family to identify his body. Sewing him not only meant closing his gaping chest wound but also sewing the whole closed in his heart. It was a pretty cool thing to get to do. It is probably the only time in my life that I will ever get to sew a heart and one of the few times that I will get to sew a chest closed.

Suturing him up was a at first an exciting and cool thing to do but as I went along the reality of the case started to hit me. I looked down at his face and eyes were still open staring right back at me, his arm was out to his side resting against my hip and then I looked at his hand. This man was wearing a wedding band, he belonged to somebody. We did not know who he was yet. He was probably supposed to be somewhere an hour ago and never arrived and they were wondering where he was. His poor wife was about to be blind sided with the worst news imaginable. Having this thought in the back of my head made me take extra care when closing him. I stayed till the very end, even assisted with putting him a body bag. That too was a first for me and hopefully the last. I really don't understand how people can do this type of medicine everyday and not have major psychological issues.

"Stupid is...stupid does."

I have come to the conclusion that trauma patients are sometimes the dumbest patients. Here is a sample of some of the geniuses that roll through our doors. Those who attempt suicide and are unsuccessful are notorious for not really thinking it through very thoroughly. We have three patients right now that are failed suicides. One of them jumped from a third story window and hit every balcony on the way down. She didn't die but did break every bone in her body from the femurs down. Another guy shot himself in the face but didn't point the gun at the right angle to do any fatal damage. He shot a hole through his tongue up through the roof of his mouth and out his mastoid (the bone behind your ear). He underwent plastic surgery last night on his tongue to put it back together again. He is now intubated but not because his brain isn't working , it's because his tongue is so swollen that it blocks his airway. Our other suicidal man also shot himself in the head. He put the gun up to his temple and pulled the trigger. He didn't have the correct angle either. This guy blew out his orbit and made a trail under his nasal bone and out above his teeth. All of these long term hospitalizations could have been avoided if they had just studied a little anatomy and physics.

Another one of our overachievers decided to run away from the cops early this morning and they let the dogs loose on him. He found out first hand just how strong the jaws of a German Sheppard are, strong enough to break your tibia and fibula. Now he needs surgery to reassemble his leg. He will heal up just in time to go to the dauphin county prison. Another one of the cities finest citizens decided it would be a good idea to shoot at the SWAT team with whom he was engaged in a standoff. They of course filled his body with 11 bullet holes. Amazingly none of them hit any vital organs and damaged them enough to kill him.

And then of course we have more than our fair share of motorcycle accidents without helmets. I saw a 45 year old woman today who was the passenger on a motorcycle and was not wearing a helmet. By the grace of God she did do any brain damage. She broke her tibia and fibula, her scapula, and 5th metacarpal. That wasn't the bad part. Her face looks like it belongs on the shoulders of a sumo wrestler. Her eyes were so swollen she can't see out of them. Her face was also completely covered in road rash. So now this once pretty woman is going to need skin grafts on her face all because she wouldn't wear a helmet. Stupid, just plain stupid!

This list could go on and on but I'll stop there. Not every trauma patient is there because of something they are responsible for, in fact most of our patients are car accident victims who happened to be in the wrong place at the wrong time. So kids, the moral of the story is don't do anything stupid enough to land in the trauma bay because I may appear sympathetic on the outside but in reality I am shaking my head in disbelief at your stupidity.

Trauma. It's not really my thing.

WARNING: this is a detailed and gruesome encounter of a trauma i saw today!!
I've finished ER and have now moved on to surgery. Instead of doing general surgery I chose to try the trauma surgery route. It's been three days and I have yet to see the inside of an OR. I have however spent more than enough time in the trauma bays. Today was the first time I have ever been in the trauma bay but I made it there three times. Two of them weren't so bad; one was a patient who was run over by a dump truck and drug 40 feet and the other fell from the top of a ladder that was two stories up. Both of these patients had non-life threatening injuries. The first trauma of the day was not quite so "nice." I was hoping my first trauma experience would be something not so intense like the man falling off the ladder but that wasn't the case.

We got the page that a level one trauma was coming in while we were in the middle of rounding. The entire team stopped mid round and ran to the trauma bays. I wasn't sure what to do but the residents were very friendly and helpful and directed me. We all threw on lead and gowned and gloved up. While waiting for the helicopter to land we were briefed on what was coming. It was a 50 y/o male who was driving a mini van and was hit by a tractor trailer. We were told he had bilateral lower extremity crush injuries which resulted in amputations and had coded in the field. We were also told that there was massive blood loss, the paramedic reported seeing 2 inches of blood on the floor of his vehicle while cutting him loose. We knew it was going to be bad. I however did not realize just how bad. The gurney came barreling through the trauma bay doors and the room exploded into chaos! There were around 20 people in the room, everyone of them doing something or looking for something. The attending was barking orders out and the team frantically attempted to follow them as quickly as possible. My eyes immediately landed on the patients mangled legs. His feet were flipped around with his toes pointing towards his back instead of the front like normal. I have never in my life seen that much blood, not even in a horror movie. It was unreal. There was not single person in the room who didn't have blood on them. The patient was in cardiac arrest when he came in so the team worked feverishly to resuscitate him. The patient would get a pulse and a rhythm then two minutes later he would lose it again. This went on for an hour and half. Every ten minutes someone knew would do compressions. You never knew when you were going to be yelled at to do something. It was overwhelming for someone who had never been in a trauma bay let alone seen one of this magnitude. Every single person was doing something different, one guy was intubating, another was putting a central line in, another was putting bilateral chest tubes in, and still another was placing tourniquets on the limbs. We ended up getting a pulse and a rhythm for long enough to transport him to the OR where we could better manage the bleeding. I did not get to go to the OR but later found out that the patient died during surgery from blood loss. When it was all said and done he had received a total of 14 units of packed cells. That's a lot of blood!

After the trauma was over everyone was utterly exhausted. We all turned into zombies for the rest of the day. It is hard to watch that kind of thing and not be affected. You replay the event over and over in your head looking for anything that you could have done better. I was later told that people who sustain crush injuries in car accidents with major blood loss very rarely survive. The battle was lost before it even began. This didn't really make me feel any better. It didn't make it any less horrific. I would be perfectly happy to never see anything like this again. I'm going to have nightmares for the next two weeks. I don't think trauma is my thing. This hospital sees an average of 2-3 traumas of this magnitude per month. This could be a very very long and emotional 6 weeks.

WARNING: This is not a happy feel good post. It's about someone dying, you might not want to read it.

Last week my preceptor and I were talking about things I needed to see and/or do yet before I'm done in the ER. She said I needed to put an NG tube in and I needed to watch somebody die. I thought that last one was a bit morbid but I figured she knew what she was talking about. I've seen and participated in several codes but amazingly they were all brought back and stabilized. I figured that I might get to put an NG tube in someone but I really didn't think I would see someone die. Literally the next day I got my chance.

From what I hear usually when someone dies in the ER there is a flurry of activity with people doing everything they can to save the person. This wasn't the case this time. This patient had liver cancer and was brought in via ambulance because she was bleeding out. The patient had requested that no heroic measures be taken or machines be used to keep her alive. So all we could do was watch and wait for her to pass. That is the hardest part in medicine, watching and waiting. I stood by watching the woman fight for every last breath...every last heart beat...every last second. The look in the woman's eyes when she realized what was happening to her was unforgettable. It was a look of complete terror and panic. I felt helpless standing there. The only thing we could do was give her pain medication to make it a little more tolerable. Slowly, with every passing minute, her pressure continued to fall and her heart rate slowed. Eventually she quit fighting and was overcome with complete peace.

Death is a necessary part of life and unfortunately as clinicians a part of life that we have to get comfortable with. I guess I'm comfortable with death in and of itself but I'm not so sure anyone can ever be okay with actually watching the human body die. Yes it's systematic in nature but you still cannot remove the humanity from it. You realize that this person is suffering and that with every organ system that shuts down that suffering increases until eventually it's over. It's a relief for everyone involved when it's over. That was one of the hardest things I've ever had to watch and sadly it probably won't be the last time I see it.

This was an experience that I will not soon forget.

I apologize ahead of time for this entry. It is going to be a bit of venting and a bit of poking fun at the expense of stupid and or lazy people. I believe the emergency room no longer deserves the title of "emergency room". It should be called the "convenience room." Twenty years ago people only came to the ER if they were either dying, hemorrhaging, or had a limb or appendage severed. This is not the case in today's world. The medical governing bodies, whoever they may be, harp on us for not getting patients in and out of the ER in a timely matter. That is because they are overcrowded by non-emergent riffraff. I've only been doing emergency medicine for four weeks but I have come to loathe these types of patients. I hate picking up a chart and seeing that they are here for an injury that occured 6 years ago. Someone needs to reevaluate the system. I have compiled a list of the top ten reasons for visiting Mercy's ER.

10)A cat scratch
9) A change in mental status but only if you are 93 and have end stage parkinsons.
8) Two mosquito bites.
7) A physical to get into the salvation army's work program. The catch is that you must have just smoked crack before you walk in.
6) "Accidentally" spraying bath and body works inside your vagina.
5) You lost your perscription for vicodin, percocet, morphine, oxycontin, and heroin the minute you walked out the ER door yesterday.
4) An invisible rash that clearly is all over your arms, feet, back and face.
3) You keep thinking that someone is constantly pulling on your "wiener".
2) Unresponsive but you have to be terminally ill, 95 years old, and have a DNR.
1) Chronic back pain for 20 years.

These are all actual chief complaints that I have seen in the ER. A few side notes about those patients, #8 called an ambulance to bring her to the ER to be seen, #6 actually had herpes, and #3 was pulling on his own wiener and didnt know it. Gotta love people.

"What we have here is a failure to communicate."

Over the past few months I have learned how imperative good communication is in medicine. I realize it's important in every area of life but we can't do our job successfully unless we are able to communicate well with our patients and with each other. Here is a prime example of a failure to communicate correctly between me, the PA I'm working with, the white board, the triage nurse, and the poor unsuspecting patient.

I randomly picked a chart up today out of the rack and it said "s/p colon resection c/o bloody muscousy discharge". On the board in the ER we have a floor plan of the entire ER and you write your patients name and chief complaint in the room that they are in. This guy's room was right next to another guy's room who was having rectal bleeding. I go into the gentleman's room and do an H&P as usual. Now somewhere between reading the chart, the board, and entering the patients room my mind decided that this patient was having rectal discharge. His entire H&P was based on the fact that I think he is bleeding from his butt. I must have asked the man 10 different questions regarding his bowel movements. We are talking extremely detailed questions like color, consistency, frequency, if he's been farting, etc. The guy just kept on answering them. He never once asked why I was asking him all of this stuff. I moved on to the physical exam. I pulled the blanket off of him and he had light reddish/pink wet stains on the front of his gown sort of over his crotch area. At this point I'm thinking 'Daaang this dude has blood coming the whole way up the front of him!' I lifted up his gown and he had a huge incision running from a few centimeters below his rib cage to just above his pubic bone. There is a serosanguinous discharge oozing very slowly from the bottom of the incision but nothing too crazy. My dense brain STILL didn't realize he was here for "incisional bloody muscousy discharge". I left the room and went and presented the case to the PA. She too was very confused by the case I presented. We both went back into the room and she started going over the same things I just did except after three questions she realized that he was here for his incision not his rectum!! As soon as we left the room I apologized and turned at least three different shades of red. Thankfully the PA I was working with is understanding of the fact that I am a stupid inexperienced student and just laughed at me.

I spent the rest of the day kicking myself and replaying that case over and over in my head trying to figure out how I could have gotten so far off base. I'm going to blame it on the fact that it was early this morning so I was not completely awake yet and the fact that it was busier in the ER than I'd ever seen it before. I'm just thankful we caught the error before I seriously violated him! Can you imagine the surprise on that man's face?! Needless to say I will be double checking everyone's chief complaints before walking through that exam room door.

Just call me the Grim Reaper

Today I saw a patient in the ER who was 64 years old. He was complaining of right chest pain, right abdominal pain, and right thoracic pain. He was also complaining of shortness of breath. His physical exam revealed absent breath sounds in the lower right lobe and a distended abdomen. He was in the ER on Sunday for the same problem and they told him he had pneumonia. The physical exam I did didn't really point to pneumonia so I expressed this concern to the PA I'm working with. She too thought there was something off. We ordered a CT of the chest, abdomen, and pelvis. The results revealed a 7 cm mass in his right upper lobe, a large pleuarl effusion, and a 4 cm mass in his sigmoid colon. :/ People don't have a tumor in their lung and in their colon and NOT have cancer. It's most likely metastasized at that point. The PA I'm working with took this information and turned it into a learning experience for me. She said that she and I would have to break the news to him since we were the ones that found it. Off we went to his room...

He took the news much better than I thought he would. We recommended that he be admitted and start the testing right away. I think he was in a state of shock and was denying that it was actually going to be cancer. One of the things he stated was that he shoudln't even be in the hospital because he was a scientologist and they don't believe in this sort of thing. They believe the body will heal itself. At this point in the conversation the attending walked into the room and told the guy not to be a "dumb shit" and let us at least figure out the severity of the situation. The patient tried to talk us out of it but eventually he seemed to grasp the seriousness of the situation and agreed to stay. I felt terrible when I left that room. This is the part of medicine that nobody talks about. I always figured the docs were the ones that had to deliver these kind of devastating blows. Unfortunately that probably won't be the last time I have to do this sort of thing. I don't think I'll ever forgot this guy.

ER Edicate

This week I started my emergency medicine rotation. I was releived to be done with psychiatry and to start doing "normal" medicine again. I thoroughly enjoyed my first day. It's fast paced and every patient has a different problem. The people I am working with are great too. They give me a lot of freedom and make every case a challenge for me. I was glad to be moving on to ER from psychiatry so I could get back to practicing medicine on "normal" people. Now I am not so obtuse that I think that the ER is full of "norma" people but I figured most would be relatively down to earth. I went wrong with this thought when I forgot the simple fact that I am in Scranton. "Normal" here is not exactly what an outsider would expect. A normal person would come into the ER, get their problem fixed then leave, never to be seen or heard from again. This is not so in Scranton. In Scranton there is no social code of ethics.

One of the cases I saw on my first day was a 29 year old male with foot pain. Being a student I did a thorough history and physical on him. We worked him up for a possible stress fracture, treated him, then sent him on his way. That was the last time I thought of the guy...until I checked my facebook tonight. I had a message from some random person that I didn't know. When I read the message it was from the guy I saw in the ER! The message itself was harmless. He was flirtatiously thanking me and complementing me on a job well done. The part that was freaky was the fact that he mentally stored my name in his head and then the next day facebook stalked me!! As if that wasn't weird enough he then attempted to contact me by writing a meaningful email. I'm going to give the guy the benefit of the doubt and say that he was just being friendly and wanted to express his gratitude. But it still freaked me out a bit. They really should rethink requiring us to have our full names on our badges. People here really have no boundries and will take any opportunity to meet you or hit on you. I have learned to expect this kind of behavior in the local bars but in the ER?? C'mon men of Scranton, pull yourselves together!

16 hours and counting

This may be a little premature but Im going to go ahead and say it, I survived psych! I only have 16 more hours left there and I'm home free, never to set foot on a pscyh unit again. I made it without being attacked, spit on, choked, or chased down the hall so I would say it was a success. The worst thing that happened was having a book thrown at me. Physically Im coming through the other side in tact but mentally is a whole other story. Being locked up with people who either tried to kill themselves and failed, have no wits about them, or are drug addicts takes a toll on you. The windows even have special screens on them to prevent people from throwing things (like themselves) through them. I dont like not being able to take my patient's word for it. When I ask someone how they are doing I expect an honest answer. In this place you are second guessing everything the patient tells you. Today was probably the most uncomfortable moment I've had here though.

I was standing at the nurses station doing documentation when out of nowhere this crazed looking man is suddenly standing with his face roughly a foot from mine. I looked up at him and said hi trying to act normal. When I looked into this man's eyes I got the most chilling feeling I've ever felt. He looked like the main character from a psycho thriller movie. You know the ones where the whole movie revolves around catching the pscyhopath who escaped from the hospital for the criminally insane. Well this guy was that psychopath. He had long stringy greasy hair, his eyes were bulging out from his face and surrounded by dark circles. He had a creepy grin that showed both his upper and lower teeth. He stared straight through me and started talking. Im not sure you could call this talking though. He was making jiberish words with this crazy sounding voice. Then he would randomly laugh this high pitched creeper of a laugh. He also decided that this time was as good as any to pee his pants. Im sure this only lasted for a minute but it felt like an eternity. I've never been so chilled from the look of a human as I was with this guy. The tech's came over when they saw what was going on and tried to convince him to walk away but he wouldnt budge. They had to physically remove him from where I was standing and put him in the isolation room. I will not be forgetting his face anytime soon. Unfortunately I will have to see this guy two or three more times before I'm done. Maybe with some luck he'll be sleeping everytime we need to see him.

I never thought I'd say it but I really miss my overweight hypertensive bacon loving cardiac patients.

One Flew Over the Cuckoo's Nest...more like I'm About to Fly Over the Cuckoo's Nest

I recently started my psychiatry rotation at a hospital in Maryland. I was not too excited for this rotation because the world of psychiatry is not really my thing. Ok so it's no where near my thing. I've been there a week and I still can say that I dont really care for it but it is very entertaining. The doctor I'm with is once again amazing. He is nothing short of hilarious and extrememly knowledgable in his field. I've mostly been doing observation and following the doc around. Next week I'm suppose to start seeing patient's on my own. I still have no idea what it is exactly that the doctor does. It appears that his job is to sit and listen while his patient jabbers on about impossible nothings. He then adjusts there medications and off they go, happy as a clam. I have learned a good bit about psych though in the past week and not just from the doctor. The patients are excellent teachers just by being themselves. Here are just a few things that these patients have taught me this week:

1) There are better ways to punish yourself besides shooting a giant hole into your own hip.
2) Trying to eat a live pet bird straight out of a cage will land you in the psych unit quicker than you can floss your teeth.
3) Apparently shooting heroin feels very similar to an orgasm. Wouldn't it be cheaper to just give all these patients a vibrator rather than building methadone clinics???
4) Walking up and down Main Street proclaiming to be Jesus Christ is concerning to some people.
5) Don't piss off gang memebers. They will chase you all over the state of Maryland and stand guard outside of the hospital that you are in waiting for your release.
6)Listening to those pesky voices when they tell you to "kill" is a bad idea.
7)Don't live with your parents until your 52 because when they up and move to Florida and leave you behind you won't know what to do with yourself.
8)Electric Convulsive Thearpy will give you one hell of a headache.
9) 75 oxycodone + 122 morphine tabs = aspiration pneumonia and a psych admit (and no im not exaggerating, a guy really took that much!)

So like I said this is just a little glimpse of the priceless knowledge I am gaining at this institution. Imagine what I'll know next week!

It Just Keeps Getting Better

Today I assisted with my first c-section and tubal ligation. It was absolutely amazing! C-sections are unlike any other surgery in that you get a lot more in return than you do with any other surgery. They're also the most bloody/messy procedure I've ever been a part of it, which is probably one of the reasons why I loved it (i'm a bit of a weird one, i know). Also what other surgery do you get a kid out of the deal. For medical freaks like me surgery in itself is a huge thrill but throw a baby into the mix and it's one of the greatest highs to be found in the medical field. I won't tell you in detail what it looked like and how it all works because I know some of you don't particularly care for that stuff but if you're interested just ask me. Let's just say you know it was a good time if when it's all over you are covered in placenta, blood, and amniotic fluid!!!

In a previous post a talked about not wanting to have a baby the conventional way but instead would opt for a section. Well I have had a serioius change of heart. The other way looks much easier and is less traumatic. The time between when the baby was removed from the uterus to when the mother was out of the OR and able to hold the baby was two hours. I felt so bad for this poor woman. She kept asking how the baby was doing and you could hear the concern and edge in her voice. So to all of you ladies who think you would rather have a c-section over a normal delivery you should seriously reconsider.

Another thing I realized was that I participated in sterilizing a woman today. I'm not really sure how I feel about that yet. It's totally her decision and she's the one who has to live with it. I have no problem with it but actually being the person who cut her tubes in half is a weird feeling. I also realized that during my cardio rotation I did a defibrillator implantation. This requires you to stop the heart to test that the defibrillator is working. So after 2 rotations I have stopped a man's heart and totally demolished a woman's reproductive tract. I am quite the little sadist. When do I get to start saving lives instead of taking them away?

I've been doing ob/gyn now for a little over a week. I really like it but it certainly was quite the change from cardio. Cardio was a lot more intense and medicinal. I don't have to walk on egg shells in this specialty and I feel comfortable here. Here when I sit down with a patient they are completely themselves and have nothing to hide. It's refreshing in a weird sort of way. The doctor is very laid back and genuinely enjoys his students. I feel like I am his priority which is always nice. I think I may be getting spoiled with the good preceptor thing. Hopefully those to come can fill their shoes.

Last Friday was a hospital day. That means it's delivering babies alllll day!!! I had been looking forward to this day all week. Turns out it's not quite as exciting as one would think, unless of course there is an emergency. We had two patients to be induced at 8am on Friday morning. Basically the day consisted of checking the patient's progression every two hours to see if they were close to delivery yet. In between checking patients there really isn't anything else to do so you study/read. (Thankfully the nurses lounge had a comfy couch that now holds the permanent imprint of my rear end.) Around 2:40 we went in and checked one of our ladies and low and behold she was fully dialated and ready for action! The last delivery I saw was my sister's birth and I was 16. I felt I was prepared for this one because afterall I had seen this before.... Oh how wrong was I. It's a little different when you are one of the people ensuring this baby makes it out ok and the mother remains in one piece (relatively speaking). The moment the doctor says the patient is ready the room explodes into a flurry of controlled chaos. Sterile gowns and gloves, "tarps", gauze, incubators and so on are flying around every which way! I'm pretty sure my eyes were the size of bulb suringes at this point. And this is just the beginning. While watching this birth and this woman work harder than she ever has I decided that no person in their right mind would ever choose to go through this. I decided that there was no way on earth I would be bringing a child into the world via the southern route. Cut me open please!

The birth was not without complications. The baby was born grey with the cord wrapped around her neck. Thankfully the doctor was fast and experienced so he handed her off to the neonatal nurses and they were able to get her to pink up rather quickly. I will spare ya'll the remainder of the details because believe you don't want to see that. Watching this beautiful baby go from inside a woman's belly to kicking and screaming right next to me was truly a miracle. Now I know why women choose to give birth, they can fully experience their childs first moments in life. And that is something nobody should miss.

This day was one of the greatest adrenalin rushes I've ever had. I can't wait for the next one!

Treat Your Trich

I experienced my first consult through texting today and I don't really recommend it. I happen to know this girl personally. This girl's name is Tinkerbell (don't want to go violating HIPPA). Her first text asked if I knew how to treat trichomoniasis aka "trich". It just so happens that I do know how to treat it. It's treated with a 2 gram dose of metronidazole (Rx only). So I replied with the treatment and she was less than thrilled with my answer. She then asked if she could take something OTC instead. "Trich" is caused by a protozoan parasite so obviously this isn't going to go away with your dose of everyday run-of-the-mill Monistat. She of course was bummed with this answer and then asked if it was just an infection, no big deal right? It was then apparent to me that this girl had no idea she was dealing with one of the nastiest looking and smelling STDs out there (the term frothy is actually used in the medical description!) I took the liberty of educating her that it was an STD and if she didn't treat the infection and her partner's infection she could become infertile. That reply shut her up for a good 45 minutes. I then received a phone call from Tinkerbell telling me that she was asking about a "friend" of hers.

This "friend" apparently went to the drug store and bought an OTC Trich test. This is news to me. Since when is Rite Aide selling STD kits? THEY DON'T!!! While this would be a fantastic way to make a fortune nobody has figured out a way to manufacture these yet. All I can picture in my mind is a little stick you pee on then match the color change up with the approriately colored STD listed on the reference card. It's genius, but not possible. The girl deserves credit for originality at the very least. I had to set her straight. So I did and I gave her a a "safe sex" talk on top of it. We don't need an outbreak of Trich occuring now, especially when I'm three days away from starting my Women's Health clinical!!

You never know what's going to walk through that door.

Last week I was doing office visits which tend to get a little rountine and monotonous. It was the next to last appointment of the day and was just a follow-up so I assumed we'd be in and out in no time. HA...famous last words!

I could hear her coming down the hall. She was yelling because she was here to see the doctor no one else. After 5 minutes of convincing her that we were all qualified to do this and that she could talk to the doc before she left, she finally caved. The first red flag came when she told me that the 30 day heart monitor she had been wearing was causing her to have heart attacks everyday. That's impossible because a heart monitor can only MONITOR you. I let that one slide chalking it up to her lack of education. I proceeded with her H&P and found that she was convinced all the doctors in the world had a conspiracy against her and weren't telling her that they screwed up somewhere. Now I'm thinking that she is looking to sue someone. Which is just great because now I have to walk on egg shells and think twice before I say anything. I finished her phyisical exam and asked if there was anything else. She then told me that "there's a lot going on inside my body." I didnt comment but she just kept going. She then told me that people snuck into her house at night and "cut her hymen off" while she was sleeping. CRRAAZZYY! First of all, we all know that you can not cut that thing off! Second of all, who talks about their vagina in a cardiologist office! Lucky me...

I just sat and stared, probably with my mouth hanging open. She didn't stop there. Next she said that little people have figured out a way to get inside of her body and are controlling her from the inside out. It was at this time that I decided that she did indeed need to see the doctor! W-O-W. And this isn't even a psych rotation. I'm afraid to see what's coming through that door next.

History in the Making

When I got up this morning I thought it was just going to be another routine day in the OR. Boy was I wrong. I quickly learned that there is no such thing as an ordinary day in medicine. The human body is sometimes unpredicatable since no two people are created the same. To make a long story short, we were putting a device into a patient's chest called a biventricular pacemaker. It's a little more involved than the typical pacemaker implant. I won't bore you all with the details but basically the doctor ran into a vessel that he could not get through. Instead of stopping and giving up he decided to try a technique he saw once when he was in France a year ago. It worked!! This procedure is not being done in the US so it was a big deal. Being a part of a ground breaking procedure is not something I thought I would be doing in my very first clinical in Scranton Pennsylvania! I feel very blessed to have a mentor that is this talented yet so willing to teach me as much as he can in the short amount of time we are given. I wonder what tomorrow will bring...

Welcome all!

I had a few requests from people to start a blog about what I was experiencing in school. So here it is folks. Enjoy...or not.

The last year of my life has revolved around 12 hours of class every day followed by 6-7 hours of studying afterwards and at least 3 exams per week. Needless to say it doesnt sound like much of a life. It was the hardest and most trying year of my life but I can't say that it was the worst year. I made some great friends and learned more about medicine than I thought was possible. I also learned a great deal about myself and what I am capable of accomplishing. Some people well tell you to join the military to find out what you are truely made of, I would argue and say go to PA school!

Now that the first year is over we are faced with yet another challenge that seems impossible to overcome: clinicals. Real patients are placed in our inexperienced hands and we are expected to find the correct way to make them better. "You want me to do what?!?" is a question that runs through my mind at least four times a day. Some days the information thrown at us seems impossible to learn and you ask yourself what in the world am I doing this for. Then there's other days, the days when it all seems to click and you help that patient get one more step closer to recovery, and you know exactly why you chose this profession. Those are the moments each and every one of us live for.