Cutting and stitching

This past week, I started my rotation at an ER in the greater Milwaukee area. It's a bit terrifying. Naturally it is a high stress, fast paced environment. Very different from where I've mostly been the last few months. Fortunately,  a lot of what we do has been urgent care type things that I feel like I have a fairly decent handle on. Granted I still feel like I don't have a clue most of the time, but it's nice when I feel confident enough to diagnose and treat something straightforward like an ear infection.

 The fun aspect of the job are the procedures - getting to physically help someone right then and there. We saw quite a few abscess and wounds that needed cutting, draining, and stitching. I need to practice my sewing skills. It seems a bit strange that cutting and needles - physically injuring the patient by causing more pain and discomfort for a time - benefits them in the long run. So often in life we seek what is comfortable, what is safe, what feels good - but the things that cause us pain and discomfort are still good for us - better even, because they make us grow.

The much less fun aspects of the job are dealing with troublesome patients. This week we had a few people who were intoxicated, substance abusers looking for more drugs, and homeless. My heart rolls through many emotions when dealing with said patients. Part of me is frustrated because they can't give a straight answer and that much of their predicament is fixable if they could only stop their toxic behaviors. Part of me is sad because we can't offer them something better than a band aid.

With thanksgiving this week, it makes me even more grateful for what I have. So often - particularly with the Black Friday push - we focus on what we lack - what we don't have - what we "need" rather than all the blessings we have. Simple things like a roof over our heads, a car that runs, food stocked in the frig and pantry, warm running water, a closet full of clothes. We could be much worse off.

Agent of change

Part of the reason I went into health care (and to Argentina) was because of my desire to help others. I want to be an agent of good, of change, of comfort and help in the world. I'm realizing how difficult that is to accomplish because of how broken people are, myself included. I feel like there is so much that I lack. I recognize that I need to trust God to cover my weaknesses by His grace and to believe He is capable of turning the impossible into a possibility. Somehow it is so easy to loose that perspective and simply hold a narrow focus on what I see before me.
On a positive note, I've had a couple people say some very encouraging things lately. I saw a patient again who remarked on the difference he noted in me - in a good way. Since I had last seen him a few weeks prior, apparently I had gained more confidence or something. Again today, another provider I've been working with off and on noted that I was really coming into my element with our first patient encounter of the morning. That was wonderful to hear particularly because on a Monday morning that I needed an extra cup of coffee for because of staying up late watching the Packer game. I was also a tad nervous about starting up again today because of being away from patients for the better part of last week while I attended a conference in Titletown and was busy with other plans over the weekend.
There is so much I don't know, but it is reassuring to note that I'm making progress when I feel like I'm spinning my tires some days.

Forgiveness

I'm struggling somewhat to figure out this PA business. It's tough being a student. I've probably said that a million times by now. It's challenging to maintain enthusiasm throughout the day when I'm hungry and tired and sick of hearing about other people's problems. My patience runs short on patients when I'm hangry and have been on my feet for several hours. I'm sorry. I wish I could say I love every minute of it, but it's stretching me. I guess that means I'm growing. Like an athlete I'm building endurance and stamina without getting burned out in the process I hope. Everyone has those days, right? When a vacation sounds nice and/or the temptation of staying in bed is nearly insurmountable...

I want to excel. Really and truly, I strive for perfection. I fall woefully short. I've been known to beat myself up over this sense of failure and inadequacy when I don't make the grade. So I'm learning to extend myself grace and accept forgiveness when I miss the mark and don't meet the high standard I set and hold myself to. I want to impress, but I need to recognize making a good impression has less to do with knowing all the right answers and more to do with treating everyone with care and respect. Academia is hard. You spend years being conditioned to achieve to answer questions appropriately for a superb grade. Out in the workplace, you are graded in a different way on evaluations. It's not always about how smart you are. No one is perfect. Yet there seems to be more pressure these days to be successful in a career, relationships, community, finances, etc. We make comparisons, but who really lives up to all that all the time? Deep down, no one. And that's ok. That's why we need grace and forgiveness and the humility to say I'm sorry. 
Remember tomorrow is a new day if we are blessed to receive it. (Lamentations 3:21-23)

I am practicing an attitude of gratitude to stave off my bemoaning the perils of student life constantly. 5 things today I am thankful for: coffee, a comfy bed, health, being able to run, cookie dough icecream. It's the simple things in life we take for granted. The gratefulness list could be a million posts, but I probably shouldn't ramble on that long. 

Another first

I saw my first live birth. Cries, pain, swearing, more cries, pain, contractions, a baby cry, blood, more pain, placenta, more cries.
Yep that about sums it up. Labor and delivery is a strange experience. It's pretty incredible to see a new life entering the world.
It was a girl!
I had absolutely no idea what I was doing, but we made it through. Everyone was doing well. I got a call in the evening from my MD who told me a patient came in at 7 cm cervix dilated already. Several hours later, her baby was born. 
Afterwards, the nurse asked me if I had any kids followed by "after that, do you want any?" Maybe someday several years from now.
Today as I mentioned I saw my first C-section. 15 pounds of twin boys came out of that operation! Wowza! That's a lot of baby.
3 babies in less than 1 day. Not bad for a small town hospital. 

Residents

Yesterday, I met some of residents in a couple senses of the word. We visited the nursing home facility affiliated with the hospital and spent some time with the family practice residents doing their thing at the clinic. I'm a little intimidated by their knowledge and experience. I know we're still learning, but technically they are doctors already. It shows in their polished presentations. I'm still mostly trying to figure stuff out and get out of surgery mode. I have to remember that I am not expected to be them. Even though we have some similar training, the name tags we wear read differently. Mine says Physician Assistant. Not MD, not DO. PA-S for now. We're all still trying to figure out what that means.

I had my first overnight call experience staffing the hospital last night. I managed to sleep. It's not like people were calling me for my brilliant medical insight, but it was a good learning experience. It's definitely a bit strange sleeping over in the hospital - not going home at all for 36 hours. It's nice that home isn't far away. I don't know how residents/interns/med students did it when they had no restrictions on the amount of time they had to work. My brain/body just doesn't function well on minimal sleep and little nutrition.

It's definitely a different set up in a smaller community. I wasn't expecting family practice to be so demanding - I mean compared to surgery it should be easy, right? Oh my naivety. It's challenging to remember everything about patients with chronic diseases and know all about prenatal care, newborns, growing kids, preventative screening guidelines for adults, medication interactions/side effects/doses, diagnostic tests. Granted, what I'm doing now probably encompasses more responsibilities in that we see everything thing from in the womb to end of life care and by taking call for the hospitalists we manage emergency admissions and post-surgical patients too.

Small towns

Today I started my longest rotation. I say longest because I'm doing 2 rotations at the same place. Fortunately in some ways, the place is home. It's nice not having to live out of a suitcase and move around every 4-8 weeks for a while. I'm on family practice and OB/GYN. It looks like I'll get to see my first C -section this week. I'm also going to be on call all night tomorrow. Yikes! Nothing like getting thrown in the first week. Hopefully I'll get more of an orientation soon especially training on the EPIC system which undoubtably will be a useful skill to put on my resume.

Today I got to see patients from 3 months to 87 years old. Quite the range! The nice thing about a small town is you know people and they know you. The bad thing about small towns is you know people and they know you. There's that awkward moment when you recognize someone that you haven't seen or talked to in more than 8 years. Or when someone else knows your parents, but you have no idea who they are. I imagine there will be more of that happening over the next couple months so I better get used to it.

outer space

On Wednesday I got to wear a space suit. We finished general surgery stuff in early afternoon. To follow was an orthopedic case that they graciously allowed me to scrub in on so I got a firsthand look at the inside of hip fracture and replacement. Because of the risks associated with cutting and drilling into bone versus soft tissue, we donned helmets that run air into the scrub suit. We were covered with a face shield and then wrapped in a sterile blue gown not to mention a few pairs of gloves. It's quite the outfit. I felt ready to walk on the moon almost. In all my shadowing experiences, I had enjoyed orthopedic surgery the most. After my general surgery rotation, I've started to question that. I guess that's okay. I mean that's what this year is for, getting experience and learning what you like and don't like to help you when you get out there. I'm not sure what I'll go into - right now I'm looking forward to family practice. I'm done with 2 rotations already! 6 more to go! I've successfully moved back home. My room looks like a disaster zone. I need to figure out what to do with my stuff. It's hard to know what you'll need and to get rid of sentimental things from days gone by. I don't enjoy packing or unpacking, despite lots of experience with it. A new adventure starts tomorrow! It's strange after 8 weeks not going back to Dodgeville. I'll miss it.

A marathon day

I put in 11 hours of general surgery today - in the OR, on the floor, in the clinic, documenting, etc. We had another case of something that my preceptor has never seen before in his many years of practice. More excitement for my last week!

It's hard to believe that I'll be done with this rotation and moving on to the next in days. I've grown fond of the people I've been working with. They've even given me a nickname. There are a few others that share my name, there's even a surgical instrument that I share a name with. It'll be hard to leave. There's a lot that I don't know which is a bit scary, but you can't expect to learn everything in 2 months either. It's tough seeing patients that we've been following and knowing I won't see them again and be able to follow up on their care after this week. For completions sake - I'd like to see the resolution. I guess that doesn't always happen in life. 
I'm celebrating the conclusion tomorrow (a bit early) with pizza and treats to share with my OR team simply because it works in the hectic schedule this week better than other days.

In other news, I ran another half marathon on Saturday with some gals I love in a city that is dear to my heart. It was a perfect day for running on a beautiful course. Later we enjoyed the sights and tastes of downtown - visiting the Farmers Market and the art museum before making our way home. Despite a nice laid back weekend following the long run, I still don't feel rested. I'm anxious about finishing well (remembering all that I should, having the stamina to last all day with enthusiasm and interest for every patient). Just a few more days.

I've gotten more suturing experience. One of the techs told me that I have steadier hands than some surgeons she knows. I fail many times, but it's always nice to get positive feedback like that. The same tech was concerned about when my last day was last week because she knew my time was short. She was relieved when I told her I'd be around for the surgeries this week because they are pretty complicated and an extra set of hands scrubbed in is handy.

Rainy days

After one of the worst summer droughts in state history, we've finally been getting some rain.
Dragging myself out of bed on a dark, rainy morning to go in to the hospital isn't easy. I'd love to stay curled up under my covers. Ah the elusive thing known as motivation. While it is tough getting out of bed, it's tough not collapsing into bed at the end of the day bypassing things like doing my studying and homework and suturing practice.
I feel somewhat reassured when I hear my Doc has also crashed on the couch at the end of a long day. It's not just me that is overcome with what seems like perpetual fatigue. I try to get enough sleep, but am never refreshed. That's why I need coffee. Like the grass perking up after a storm, I tend to gain more life after a warm cup of joe. A vacation would be better, but there's no time. I enjoy the fact that this program is condensed - 2 years isn't a very long time from start to finish, but sometimes it would be nice to have more recovery room to try to relax from the stress.

Llamas doing the limbo...

Something I never expected to see, but did at the Wisconsin State Fair! Llamas and all sorts of animals strutting their stuff.
I had a great weekend - visiting friends, seeing family, eating good food, etc. I probably keep myself too busy - trying to do and see as much as I can. Going between a few of my favorite places in the state (home, Madtown, Milwaukee). When you are faced with people dying from ailments at work, I guess it makes you want to live and experience as much as you can. I wonder where I'll end up. It's funny that even as we age and bodies change - sometimes it seems as if we're all still young at heart - under the impression that we'll live "forever" until some news shocks us into remembering each day is a gift and we all have an expiration date on this life. 

Surgery hasn't been what I expected either. I've seen and done things I didn't think I would at this point in my career. Every day, I never quite know what I will encounter. I try to prepare, but face the unknown. It can be tough not knowing the answer, especially when you have patients that desperately want reassurance. I'm finding it's difficult finding the balance between offering them hope and cheer, but still being realistic about possible less than desirable outcomes.
Hope. Truth. Faith. Life.

Knowledge is power?

There are many days when I just don't know the answer. It's disheartening. I feel like I should, but I lack the experience or discipline studying or brain recall memory or something. Missing neurological signals

As a health care professional, we are expected to know: anatomy, physiology, pharmacology, psychology, gender and cultural aspects impacting care, evidence based practice techniques, associated costs/risks/benefits of treatment and diagnostic options, statistics, medical terminology, cancer recommendation guidelines, how to resuscitate someone, reference ranges and indications of diagnostic tests, how to navigate health care system computer software, how to counsel/teach, how to read imaging studies, how to accurately measure, essentially a little bit of everything!
It's overwhelming. I realize no one person is expected to know everything, that's why we work in a team, but patients look to us expecting us to have a solution a lot of the time.

In the name of medicine...

Today I stitched up my first awake patient. He had skin cancer that the surgeon sliced out. Then we had to sew him back together.
Everyday seems to have a new learning experience. It's hard to keep up - hence the slight blogging hiatus that I'm trying to catch up from.

Last week, I felt as if I was torturing people in the name of medicine, while they slept.
As one of the MDs said, "you can go home and tell mom that you stabbed someone today." I cut someone open with a scalpel. It was a tiny incision on a laparoscopic procedure - but it was still a sharp knife. Then I poked them with a needle repeatedly in an effort to stitch them shut again. 

I also yanked some poor kid's toenail off. He asked for it. Really - it had been bothering him for a long time. When they say general surgery - they sure mean general! I was not expecting to have to do that. There's definitely a bit of a grossed out feeling that comes with peeling the nail off. Gruesome. Maybe even worse than blood and guts. 

In other news, after those interesting experiences (you'll never guess what I did today...) I went home and enjoyed a nice weekend with family. My uncle who lives on the other side of the country was visiting Wisconsin so we had a mini reunion.

Tagging along

Today I'm enjoying a break from the hospital/clinic thanks to it being my preceptors day off and it being a physician's golf outing that his partner is attending. Why anyone would want to golf in 90+* humidity in July is beyond me, but I've never really liked golf.
I started off my day with a long run seeing as I'm running a few more half marathons and signed up for a marathon this fall. I was plodding along the country roads when a medium sized black dog comes running up to me. I stopped, waited for it to leave, but it playfully tried to jump up and scratched me. I decided to keep running since I had a few more turns to go (I was just over half way done). I figured the dog would get hot, bored, turn around, and leave me alone. I was mistaken. It followed me the whole way back (5 miles!) despite my attempts to dissuade it by stopping and saying sternly "no, stop, go home!"  It didn't understand that I was not interested in a canine running buddy today. It didn't run right next to me the whole way, it would run off and stop to sniff at things along the way. I thought for sure it would be distracted and go away eventually. It seemed like a smart enough animal in that it would stay out of the road when a car came along for which I was grateful because I was not eager to take responsibility for it. Yet, it was dumb enough to run miles with me in this heat/humidity. It was slobbering up a storm from all its panting. When I got back to the farm, I went inside to shower and have breakfast and ignored it completely. I had other things to do today than worry about someone else's dog. I like animals especially dogs, but I wasn't a fan of a strange one following me on my morning run. It was kind of annoying. I was worried it would mess with the old cat that lives around here. When I left the house a bit later, I didn't see the dog hanging out so maybe it did make the trek back. It didn't have a name tag to identify it on the collar so I couldn't say for sure to whom it belongs.
Some days in rotations, ok - most days, I feel a bit like the dog, a bother, just tagging along. I trail the providers I work with as best I can... Seeking to please and often failing. Not always understanding and getting distracted easily by everything that's going on around me. Mostly just trying to keep up with the pace and stay out of the way so I don't get hit. By the end I'm exhausted and in desperate need of a drink. 
Most of the rest of the day I've been studying. Taking a relaxing study break. Study. Break. More break than study. My brain needs time to let it all sink in.

Circ

Today I got to see more little ones and even help out with doing medication follow ups. After the clinic closed, I went over to the hospital with the MD for a circumcision on a baby boy. Just to observe something you don't see every day. Due to a minor complication that the MD hadn't experienced before, he bled a bit more than usual and understandably wasn't happy. That was interesting. I'm sure I could make many jokes about it if I wasn't so tired from the longer hours. Without an extra computer at the office today, I still have to do all my documentation for the day as well. Ah homework. It never seems to end.
We also discussed some other interesting cases today - everything from ethical dilemmas to handling developmentally delayed children. There's so much to keep track of - insurance issues, medication interactions, etc.

Difficult cases

I wondered what it would be like working in Pediatrics. I love kids. They can be so much fun. They can be pests too, but mostly I find their energy and creative entertaining. I worried about seeing them when they are sick, because then they are pretty miserable - crying, screaming, dripping, etc. It's just tough to see someone so little in pain. I guess I'm lucky I only have to deal with them for brief intervals. Mostly they are a joy to work with - only a handful are difficult. That's where some coaxing comes in. The nurses have the task of giving the dreaded shots.
Today was a bit more challenging. We had a 6 year old girl come in. She didn't want to be touched at all and was hesitant to answer questions. She was even ashamed to admit certain things. Her mom had some concerns and reason to believe that her daughter had been molested by another person in the house. Abuse is awful and tough. It's not something you ever want to see or hear about. For me, it sucks the air out of the room. How do you put on a happy face and move on after a child's innocence has been tampered with? I think it's hard even to hand over a report to someone and not know if justice will be made. The other providers are great at handling such a delicate and important subject.
It's overwhelming and heartbreaking. And it's only Monday. This could be a long week.

Babies

Some of my favorite patients are the smallest ones. It's exciting to see newborn babies and a little scary because they are so tiny and vulnerable. As someone without any kids and so new at this PA business, sometimes I feel like I need as much reassurance as the new parents do. They often have lots of questions. I'm supposed to have the answers, but don't quite feel qualified yet. Their babies come in all shapes and sizes - lots of variability still equals "normal." One of my highlights from the week was seeing a baby boy on Monday and again later in the week to monitor his growth. We'll see him again next week probably as a 2 week check up is pretty standard. It's cool seeing the same faces even when I'm only here a few weeks.

Mini victories

Today I saw a few more patients on my own at first. One guy I was particularly excited about because he came in with a growth on his toe. It was a wart! There is something immensely satisfying about being able to reach a diagnosis and have a treatment plan ready to recommend. Most of the time when I went in the room, I wasn't sure what was going on and wanted to double check with the Doc, to see what they think, but this time I actually knew what I was doing. Obviously, it's still early on, so the MD comes in afterward anyway and goes through everything to make sure I haven't missed something and performs the necessary procedures, but soon enough I hope to get to be doing that stuff myself.
It's funny that when I'm shadowing, I'm thinking "yeah I could totally do this" and then when it's just me in the room I'm nervous and forgetting the basics. Hopefully that will go away with time and experience.
Something else interesting has been the number of kids with ADHD and other behavioral problems that are on medications. It concerns me to mess with their brain chemistry from such young ages by having them on drugs. I guess I can't always tell from a brief session what their needs are in different settings like the home and school.
More mini victories ensue when I could tell what a drug is that the NP didn't recognize. That sort of thing doesn't happen often. Most of the time I'm clueless when I hear the MDs throw around a medication name because we didn't learn all of the brand names for drugs in pharmacology. Even when they tell me what class of medication it is - I feel like I'm still fumbling around, wracking my brain to find what it is associated with - the side effects and that sort of thing. I suppose that's normal since it's so early on in the year, by the end hopefully I'll have more of it down. Even then I won't know everything. It's a constant learning process.

day 2: some firsts!

Today was my second day of rotations ever. I got to see a couple patients on my own briefly to report back to the MD I was with. It's nerve wracking when you are the one doing it. I'm still working on getting a routine down and getting familiar with the computer system. The other major new thing that happened was that one of the patients we saw today was diagnosed with leukemia. This little boy had been in for a few visits, with some other health concerns that didn't really point to the cancer diagnosis. From the diagnostic tests today, it revealed this abnormality. Uff. Try explaining that one to concerned parents. Goodness. No one wants to hear that they have cancer, much less their child. Fortunately the prognosis is pretty good, with treatment kiddos tend to do well. It was the first time my precepting physician had to give that diagnosis to her clients. Rough. Working in health care - you get to see the behind the scenes stuff that physicians do - like trying to check with the insurance company to see where they can refer this patient for oncologic services to be prepared with information for the concerned party.

My first day

Today was my first day of clinical rotations. I guess that means it's official, I'm in my second year of PA school. Most of the day was just spent shadowing the MDs and NPs that work there - getting familiar with how they do things. As the weeks progress, I hope to do more - seeing patients on my own first and comparing notes with the providers. It's a small practice, but everyone seems really nice. I tried to get oriented and help as much as I could. I was complimented by the nurse who found me cleaning up in one of the exam rooms and I even showed the MD where she could find a mask from my exploration in the cabinets and drawers.
With the other health care providers I saw newborn babies and kids up to 18 years old! Quite the variety. I'm learning a lot - there's a ton that I don't know. We also had a patient that required a Spanish interpreter. For a small community like Beaver Dam, I wasn't expecting it, but I guess they have a decent Hispanic population that they cater to with materials in Spanish. I definitely like to see that.

Rotations are tough though. People always say it's like an extended job interview. Sometimes, students are offered a job at the end of their rotation if they are well liked by the providers and such. By the end of the day, I'm exhausted from trying to absorb so much information and trying to recall just as much information that I theoretically learned over the last year. Then I have to do a lot of documenting as well as other projects and try to study up on things. I'm not sure how I'll manage to keep up my energy and enthusiasm, much less my health. Being around so many sick kids can't be good for my immune system - no matter how much handwashing and sanitizing you try to do throughout the day.

Endings and New Beginnings

It's been at least a year since I've posted a blog. I haven't been writing much lately with the exception of trying to crank out a massive literature review assignment precisely because I've been so busy with my graduate school program of studying to be a PA. I've decided to start blogging again and revamp the site in an effort to chronicle my experiences in the clinical year of my program. I'm starting over again with new adventures.
Every 2-8 weeks or so I'll be beginning a new clinical rotation at a different site in a different area of medicine.  Basically I'll have a nomadic lifestyle - carting my suitcase around in my car while I eat, sleep, and breathe medicine. I'm leaving the apartment I've had in Waukesha for the last year where I attended class and won't have a place of my own for several month. Rather, I'm staying with family and some other good souls that are willing to adopt me over the course of the year to provide me with housing for my endeavors that will take me all over the southern half of the state.
 With all the change and transition this will entail, I make no promises as to frequency of posts. But I hope this can be a way for my friends to keep tabs on where I am and how I'm doing. If nothing else, it will be neat to reflect on once I'm out of this school/training business and back into the "real world" with a career in health care somewhere to be determined.
It's been suggested by curious friends that because I'm moving around so much and it's hard to know where I'll be when, I should have a GPS system or app of some kind to reveal those details to only people to whom I reveal the secret password in an effort to prevent unsavory characters from hunting me down with said tracking device. This record may be a reasonable alternative--less hassle at least.
Today marks my last day of the didactic year. My classroom setting will change dramatically form the same room at the university graduate center to the clinic and hospital environment in just a few weeks.

Tomorrow I'll be headed to Toronto, Canada for a national PA conference that they hold annually. Shortly after I return, I'll be preparing to go on my first rotation in Beaver Dam for Pediatrics.
Stay tuned.

Disclaimer: Due to confidentially reasons, no patient or provider personal information will be included in any of my posts.