It's All About the "C" (30/30)

     What a month.

     May has simply flown by, which I suppose is not very surprising considering all the big events it included. In this month I've attended four graduations, taken one 3-day review class, summitted two mountains on a 4.5 mile hike, visited three states, helped coordinate one very big surprise, and taken one 6-hour exam. In between all that I used every spare moment to study for the Physician Assistant National Certifying Exam (PANCE). I attempted to use my study breaks to finish a post on my final rotation, but that one still needs a bit of work so today I'm skipping ahead to the milestones I hit this month. To start at the beginning: I GRADUATED!

     I finished my final rotation on April 27th, had my final graduate seminar and End of Rotation Exam the next two days, and then spent the beginning of the next week taking a 3-day day PANCE review class, before it was finally time to walk across the stage and end my time in PA school, officially. My graduation happened to fall on the exact same day as my sister's (she earned her Master's in Education), so my family not only endured the bitter cold and drizzly rain of a May morning at Gillette stadium, but they also drove straight from my commencement to arrive just in time to sit through a second outdoor ceremony in Quincy. My Californian aunt and uncle had to stock up on some extra layers, but they joined my parents and roommate in enduring the weather to show their love and support for us. There were cheers and pictures and hugs and toasts and celebratory feasts and everything one could need to feel loved and encouraged. As an added bonus, MCPHS actually had diplomas ready for graduates on the day of graduation so, rather than having to wait a few weeks for it to arrive in the mail, I left Gillette with proof that I had, in fact, completed PA school.

My cold, but wonderful, uncle and aunt

My long-suffering, and always encouraging, roommate

My parents, who have supported me in every imaginable way

My brother in-law and sister, both of whom completed their Master's this month

Mother's Day hike to Mt. Welch and Mt. Dickey

     After graduation I took a well-deserved, though brief, break to celebrate Mother's Day with mine and my brother in-law's families, and then it was back to studying. The NCCPA requires that PAs wait at least 7-10 days after graduating before they attempt to take the PANCE, but otherwise the choice of when you take the exam is up to you. Seeing as my brother in-law was about to graduate with his Master's on the 22nd, and his thesis art show was on the 20th, I scheduled my exam for the 19th. I wanted time to study, but I also didn't want to have the exam hanging over my head while I tried to participate in the upcoming celebrations and family time. So, from May 9th until the 19th, it was non-stop studying, with few exceptions. My roommate needed to calm me down on the 17th, when I suddenly became convinced that I must be woefully unprepared for the exam, but after some

Studying at my friend's graduation

reassurance, and a massage on the 18th to help relax me (thanks parents!), I entered the testing room on the 19th feeling surprisingly calm and ready to tackle the PANCE. The exam can take up to 6 hours (there are five 1-hour blocks, and 45 minutes of break time), but thankfully I was able to finish up at least an hour ahead of time, even with the breaks I took mid-exam to do some deep breathing. Even though traffic on the drive home was horrendous, it was such a relief to be done. Plus, I knew that my roommate and friends from the coffee shop were waiting to hang out and celebrate with me. All these people deserve a shoutout and a huge debt of gratitude for all the support they have given me over the years, not to mention all the times they've cheered me up, made me laugh, switched shifts with me, and even helped me study. They belong to the very long list of people I couldn't have made it through PA school without.

     My classmates and I had been informed that it would take 2 weeks to get our PANCE results, so it was with some surprise that, a few hours short of one week after I'd taken my exam, I received an email informing me that my results were ready. To be completely honest, I got this email early in the morning and actually fell back asleep briefly, only to be haunted by a nightmare in which I was told I had failed, so it was with some trepidation that I longed onto the NCCPA site when I woke up again. Before I could even get to the page with my exam results though, I knew. There, underneath my name on my profile page, was a bright and shiny:

Obviously after my nightmare I needed confirmation, so I quickly clicked on the Exams tab to find:

     Just like that, ladies and gentlemen, I am official. I am a certified PA and, while I still need my state and drug license before I can actually start working, those licenses are simply a matter of paperwork and time. The hard part is over. I am a really and truly Physician Assistant at last.

     There are more people who deserve gratitude for getting me to this point, and trying to list all of them would take too long (though I did try in my last Thanksgiving post), but for now let me once again give a shout out to some of the people I haven't already mentioned in this post: my older sister, who sadly couldn't make it to my graduation, but was able to celebrate belatedly when she came for my brother in-law's; my grandparents, my aunt and uncle in Seattle, my cousins, and all my extended family who couldn't come to the graduations but were there in spirit; the friends who have mentored me throughout these years and guided me not just through my studies, but through the emotional, spiritual, and psychological trials I've encountered; the health care professionals who gave me advice, encouragement, and sometimes a necessary push; and last, but certainly not least, my Bible study girls, who supported and encouraged me every week, not just with prayers, but by always going above and beyond (e.g. offering to run errands for me when rotations made me insanely busy and buying me an ice cream cake to celebrate the last day of my final rotation). I do not have the words to adequately express my gratitude, so I shall simply say: thank you from the bottom of my heart.

     At some point I will actually finish my post on my final rotation, and I'll probably write a short one on the PANCE (just a few tips for anyone studying for it), but for right now I'm going to bask a little in the fact that I am not simply a PA, but a PA-C, and that I am well and truly done with PA school. 

Life is Open Book: Family Medicine (28/30)

I do miss having this as a view on my commute to work.

These two are alright.

     I've mentioned in previous posts that an important part of clinical rotations is learning to be flexible. This was certainly true regarding my rotation for Medicine 2*. I had originally been scheduled to return to my Primary Care site for a second rotation there, but plans don't always go the way they're supposed to, and, before my initial Primary Care rotation was even over, I found myself working together with my clinical coordinators to find a new site for Medicine 2. As luck would have it, my Medicine 2 rotation was scheduled for the first block after Christmas break, and my coordinators were completely willing to let me pursue a rotation back in Oregon, which meant that I could come back for the holidays and stay for 2 months. It took about 6 months to get all the pieces in place, with multiple people on both sides of the country working tirelessly to make the rotation a reality, and I technically didn't receive the final stamp of approval until just 4 days before my rotation was scheduled to start, but it all went through in the end, which is how I found myself doing Family Medicine in Oregon this January. 

I do not get to see my cousin, or her
kiddos, nearly enough.

     Having almost two full months in Oregon was wonderful. This meant that, even before I started my rotation, I had my own form of "family medicine." I was able to not only live at home with my parents and sister (and kitty!), but also see all my grandparents (even getting to celebrate one grandma's 88th birthday), and much of my extended family. The last time I'd seen my cousin's boys was last Christmas, which was much too long ago (especially given how fast kids grow), but being home for my rotation meant I got to play around with them on two separate visits! I not only had quality time with family, but I was able to catch up with friends, some of whom I hadn't seen in years. Having two months in which to see everyone was so much nicer than trying to cram all the visits into 7-10 short days like I usually have to do. I certainly had less time to hang out once my rotation started, but it was alright because family medicine was quite enjoyable, and chock-full of important lessons, some of which were new, and some which I simply needed to re-learn.

MAs are also super helpful
with doing procedures like
orthostatic vital signs.

     One important lesson I was reminded of was to learn from everyone around you. As students we know (or at least we should know) that we have much to learn from our patients and our preceptors, be they PAs or physicians. Sometimes, however, we forget that there are many more people who can teach us, and, as an introvert, it can be difficult for me to reach outside my comfort zone to talk to yet another unfamiliar person. It's worth it though. Especially when you're a student or new provider, the wisdom that can be gleaned from the MAs, nurses, floor managers, etc. is invaluable. During my first two weeks in family medicine I often worked with an MA who gave me her spiel on each patient before I went to see them. She'd been an MA long enough that she was often quite good at guessing common diagnoses and she usually added a couple tidbits about the patient's personality or attitude. Even if I didn't always agree with her proposed diagnosis or interpretation of the patient's character, I still found her insights helpful, I loved that she prepared patients to be seen by me, and it was always nice to be forewarned when a patient was hostile. 

Picture taken with patient's permission.
I took that hook out, and the next
day removed another foreign
body from an ear.

     Another thing I needed to be reminded of was that sometimes Nike is right; sometimes you need to just do it. In the case of family medicine, this meant being willing to do new procedures and see unusual or difficult patients. Both the PAs I worked with during family medicine performed procedures and provided cross-coverage care  for their practices. This kept the days interesting, as the regular routine of patient visits was broken up by small procedures like skin biopsies or joint injections, and even the regular patient visits were often surprises since many were same day appointments or walk-ins. I'd done plenty of joint injections during my orthopedic rotation, but family medicine was the first time I'd done trigger point, bursa, or tendon sheath injections, and I certainly hadn't done any skin biopsies or fishing hook removals on my previous rotations. It's always a bit nerve-wracking to try something new, and often the desire to learn a new skill is dampened by the fear of failure or disappointing your preceptor. The fact is though, you'll never learn if you never try, and sometimes you have to just be bold and do it. Now, obviously, this doesn't mean that any time a preceptor offers to let you do a procedure you just waltz right in without preparation or supervision. For the trigger point and bursa injections, I followed the "see one, do one" pattern. For my punch biopsy though, my preceptor talked me through the steps before I entered the room, and then watched me do it, providing additional coaching as needed. I'm glad I didn't demand to see one first as that was the only punch biopsy we did, and it's really something you can only learn by doing. Sometimes I was nervous, but both my preceptors were great coaches and pushed me when I was hesitant, usually proving that I was more competent than I'd realized. I say usually because no learning process is ever mistake free. My first shave biopsy was excellent, and I think I definitely got the hang of toenail removals, but the first time I froze a wart on someone other than myself I managed to give them a blister because I had not yet mastered the staccato pattern of administering the freezing spray, which is so necessary to keeping the affected area small. I felt awful when the patient returned with their blistered foot the next day. I still feel awful, and I was definitely reluctant to try freezing the next wart that came through. But I did. You have to. You cannot be paralyzed by fear of failing when learning; you simply have to make sure that you are learning new skills in a safe manner, under guidance, and that you minimize the risk of damages as much as possible. When you do mess up (and you will), apologize and learn.

Impromptu lessons on alveoli and pulmonary
vasculature in different disease states.

     The last lesson I learned was one I really should have known already. In fact, before I started clinical rotations, PA students from the year ahead of me met with my class and even told us about it. The lesson? Admit when you don't know an answer. Now, I've known for a long time how important it is to know what you don't know, and I've certainly made it a point to look up anything I didn't know right away, but admitting when you have no clue is easier said than done. In school you cannot simply leave a question blank on a test or say "I don't know" in the middle of a practical exam, so when stumped you get into a habit of throwing out answers and demonstrating your train of thought, hoping to get partial credit, and it's hard to fight the training of always needing an answer. One of the doctors I worked with during my first two weeks figured this out about me very quickly. He then made a point of asking me questions to which he knew that I did not know the answer, just to see how long it would take me to say, "I don't know." 

A walk-in patient we promptly sent to the ED. The right
picture was taken first, and shows a pneumothorax in
his right lung. 

     In the instance I remember best, he'd asked me to see a patient who had been scratched by a monkey on a visit to a southeast Asian country, and then asked me what we should do with her. I was at a loss. In my head, I was planning to look up the shot she'd been given shortly after the incident to determine what it was and whether she needed more, followed by further investigation into what foreign illnesses were endemic to that area, but the truth is that I could not give any definitive answer as to the plan until I knew more information. Rather than simply saying that I didn't know and needed to get more information, I rattled off what I did know: the incident happened 3 weeks ago, the wound was well healed without any sign of infection, and the patient seemed completely healthy and without any systemic symptoms. The doctor was in the middle of asking me if, based on that, I really thought she could just be sent home, when his phone rang. It was the Infectious Disease consult he'd requested while I was in seeing the patient. The point of his lesson was immediately clear: even physicians who have been practicing for years need to ask for help, or, as he put it, "life is open book. Use your resources." I'll admit that there were still times during the rest of the rotation when I struggled to provide an answer rather than asking for a minute to do some quick research first but I did learn. In an interesting twist, I even discovered that you sort of can answer "I don't know" on an exam in PA school. When I did my OSCE,* I forgot to ask my "patient" one part of her history. It didn't actually affect her diagnosis or treatment, but when my proctor asked me a question that related to this information, I had to answer with, "I don't know, but I can ask the patient." My proctor smiled, thanked me for not making up the information, and passed me. In medicine, as well as the rest of life, honesty (and humility) really is the best policy. Acting the "cowboy" might save you some embarrassment, briefly, but sooner or later, it will hurt your patients.
     There are far more lessons I learned, and far more stories I could tell, but time grows short and this post grows long, so instead I'll simply leave you with this bit of advice from my beloved Dutch Bros Coffee: 

*All PA students are required to have two rotations in general medicine, one of which should be inpatient, usually internal medicine. The second is more flexible and can be in anything from primary care to family medicine to women's health to rehab to geriatrics, as long as it's not overly specialized. 
*Objective Structured Clinical Examination -basically a practical skills exam that all medical and PA students have to perform and pass in order to graduate. Part of it includes performing aspects of the physical exam as instructed, and another part is taking the patient's history, asking for the physical exam and lab findings (without actually performing the exam), and presenting your assessment and plan to both the proctor and the patient in medical and then layman's terminology.

Dem Bones: Orthopedics Elective

     I'm already starting week 3 of my eighth rotation, but it's taken me until now to finally finish writing about my sixth rotation: my elective in orthopedics. I will admit that when I initially ranked orthopedics as a high preference for my elective rotation, I did it primarily because the rotation site was only 3 miles from my apartment, and I'll also admit that it was so very nice to have such a short commute, especially after months of commutes that usually lasted an hour (if not two) each way. However, in my life I have often found that some of the things I've done for purely practical (or at least not lofty) motives, have sometimes turned out to be some of the best things I've done. I think this was the case with my orthopedics rotation, which quickly became one of my favorites. 

     The biggest factor in my enjoyment of this rotation came from the people there. The practice was made up of both PAs and MDs, plus the radiologists, scrub techs, and administrative staff, and it often felt like a big family. My very first day I noticed the picture at right and felt put at ease by the obvious sense of humor that seemed to pervade the office. Soon I noticed more and more signs: a My Little Pony sticker on the hand sanitizer, evil eyebrows and mustache on a baby photo, even fart jokes on a calendar. I learned that practical jokes happened fairly often, and that, once everyone was comfortable with you, sarcastic and snarky quips would be headed your way. It was great. It frequently felt like I was back at the coffee shop with my wonderful coworkers there but, instead of catering to customers, I was caring for patients. It was truly the people who made this rotation so enjoyable, and after emergency medicine, where I'd had a different preceptor almost every shift (which made it difficult to know and become comfortable with any of them), it was a relief to feel relaxed and like I belonged. As I'm now looking at applying for jobs and beginning my life as a PA-C, this rotation was an excellent reminder that the people you work with can make or break a position. Before this rotation I had not been particularly interested in orthopedics, but I began to think that it was maybe something I should look into, if only so that I could work in such an environment with such people. 

Hoppenfeld's, the classic text on orthopedic
examination, has some great illustrations

     It wasn't just the sense of humor and friendliness of the office that was so appealing; everyone was eager to teach. Again, compared to some of my previous rotations, this was a dream come true. Rather than feeling like a nuisance or that my presence only slowed things down, the doctors and PAs took time to train me, going over the way they performed exams or presented patients or did procedures. I think it worked out pretty well for everyone, because by the end of the rotation I began to function similarly to one of the PAs employed by the practice. I would see patients, presenting them to my supervisor with my assessment and plan, and would move on to see the next patient while they checked out my first. Then, by the time they finished, I was prepared with the next patient and could keep things moving smoothly. Obviously I was still learning and I wasn't correct 100% of the time, but it certainly boosts your confidence to have the MD or PA come out of the room and say, "I agree with what your assessment. Go give them a shot/PT referral/prescription/etc." If I was off, they always made sure to explain why they thought differently and went over any exam findings I missed or extra tests I could have done to get a better differential. It was excellent. 

This doctor looks way too pleased to be
palpating some glutes.

     Another things my preceptors did wonderfully? They made their patients active participants in their care and made sure their voices were heard. One thing you definitely notice in medicine is that patients can often fall into one of two extremes: either they have little to no trust for any clinicians (sometimes reasonable, and sometimes not), or they put all their trust in their clinicians and prefer not to make any decisions themselves. There are frustrations to dealing with both kinds of patients, but whether the patient assumes that a provider is only suggesting a treatment because they're greedy and want money, or the patient is prepared to let the provider make any and all decisions, it's important to hear from the patient and get a sense of what was most important to them when it came to their issues and treatment. This was often obvious in orthopedics. If a patient came in with horrible arthritis of their knees, we could be fairly certain that NSAIDs and cortisone injections might help to keep the pain under control, but they wouldn't cure the problem, and that a knee replacement would probably be needed in the future. The question was most often when, not if. However, the timing of such an operation was not really a question we could answer. We needed to know if the patient could take time off from work, could get help while they recovered, and if the surgery would allow them to continue to participate in the activities they enjoyed. The question tended to come down to "how does this pain affect the life of the patient, and when do the cons of the surgery become less than the cons of life without it?" Only the patient could answer that. We could provide information (e.g. how long the recovery time was, what the chances of improvement were, how long the alternative therapies might work, what activities will be limited after a replacement) and advice, but, though some patients asked, we could not make that choice for them. I really appreciated how the MDs and PAs were willing to have these conversations, often multiple times, so that the patients had a chance to ask all their questions, voice all their concerns, and express their values. It might have required more time and effort, but I think it was best for everyone in the long run, especially the patients. 

This is not normal. Just FYI.

     One last kernel of wisdom I learned during my time in orthopedics, which is relevant to both patients and clinicians, is that you "treat the patient, not the imaging." Many times we had patients who came in and thought if they just had an x-ray or a CT or an MRI, their problem would be obvious, and they sometimes became upset that we insisted on taking a history and doing a physical exam. The truth that we had to explain to them was that imaging gives us just that: an image, a picture of their anatomy. It doesn't come with a diagnosis written at the top, and even when radiologists provide a report, they are rarely 100% certain of the diagnosis. Often a read comes back that says something like, "abnormalities consistent with a or b, but c, d, or e cannot be excluded at this time. Please correlate with clinical exam." Certainly there are times when the imaging seems obvious, but even then the history and exam are important. Time after time we'd see an x-ray that showed horrible arthritis or bunions, only to discover that it was the other foot or knee, or even something entirely different, that actually bothered the patient. Sometimes we had the opposite problem: someone's x-ray seemed normal, but they were in horrible pain or had lost function of a joint. Those were often harder discussions. We'd have to explain that all imaging is limited, each imaging modality is better for different things (e.g. x-rays are great for bones but not soft tissues), some abnormalities in anatomy don't even show up in imaging right away, and that, all too often, getting the imaging doesn't change how we treat the problem. These hard discussions seemed to come up most frequently with spine patients. Those patients often had very painful problems, but the treatments we have for back issues are still rather limited or take a good deal of time, so it was understandable that they were eager to have any and every imaging if it meant finding a solution for their pain. Sadly, imaging for spine problems isn't always helpful or justified, or at least not right away, so frequently we had to give the hard and disappointing answer. Whether you're a PA, MD, NP, nurse, etc., most of us went into medicine to help and to heal, which makes it so much harder when our options to do just that are limited, or when the timeline is longer than we'd like. This is the situation we clinicians live in, however, and until someone figures out how to cure every ailment in the world, we have to acknowledge these difficult issues, be honest with our patients when they arise, explain all the options, and then work with our patients to do whatever we can to aid healing and alleviate pain. It's not always easy to do, but it can be done, as my time in orthopedics showed me over and over again. 

Don't Believe What You See On TV (24/30)

     Last Tuesday was the last day of my rotation in emergency medicine. Looking back it's hard to come up with a summary of this rotation. I worked 17 shifts, saw 100+ patients, had only a few repeat diagnoses, and performed quite a few procedures. I suppose the only general statement I think I could make is to say that the ED does not lack in variety. Sure, there are particular conditions that are seen commonly, but you show up each day for your shift not knowing what you will see. Even the "common" conditions aren't always that common, or don't present in the same manner each time. Take appendicitis for example. During my surgical rotation I saw a woman with appendicitis who presented with left-sided, rather than right-sided, lower abdominal pain. It turned out that she had a long, midline appendix that extended into the left abdomen. Then on this ED rotation there was a man with right-sided diverticulitis and a boy with a right-sided abdominal abscess who both presented similar to acute appendicitis. It wasn't until my last day in the pediatric ED that I actually saw a case of appendicitis that fit the "classic" presentation, and even then the patient had not yet developed a fever, as is common. 

Being woken up by solicitors
after my last overnight shift.

     The variety of the ED was also aided by the fact that, for this rotation, I didn't stay in the same area of the ED for all shifts. My schedule was 3 days on/3 days off, and for each group of 3 days I was in a different location. I had six 12-hour shifts in the main ED (3 overnight, 3 during the day), three 9-hour shifts in the more psych side of the main ED, four 8-hour shifts in the pediatric side (I covered one shift for another student), three 10-hour shifts in the fast track, and one 8-hour shift on an ambulance. It's really no wonder that this rotation seems to have flown by. I actually enjoyed all areas of the ED, but it was nice that if a student really didn't like one area, they only had to do three shifts there. That was definitely nice in regard to the overnight shifts. I actually saw a lot of interesting things on those shifts, but man did they mess with your sleeping and eating schedules. I spent the next 1-2 days after those just recovering and trying to remember what day it was. It didn't help that there were mandatory lectures two days each week, so for two of my overnight shifts I couldn't even go home when I got off at 7 AM, but had to go to lecture and finally leave around 9 AM and 11 AM. That was painful. At least when it was quiet I had the opportunity twice to head over to the fast track side and nap in a bed for a bit. It was actually quiet enough that I got about 2 hours of sleep/nap one day.

How I got a few winks during overnights

     If you're surprised that I got any sleep while working in an ED, I should mention that E.R. and other medical dramas on TV can be a bit misleading about the day-to-day life in emergency medicine. There are quiet times when the only patients in the ED are ones waiting to be admitted. There's also just a lot of waiting. One of the attendings with whom I worked quipped that a more accurate TV show about the ED would just be a lot of people sitting around typing on their computers and waiting for lab results to come back. That's often a fairly accurate description. The waiting can be very frustrating for both providers and patients (and certainly the patient's family members), but it is a regular part of ED life. Later at night in particular it can take longer because there are fewer staff in the lab or imaging. Particular days, like Mondays (apparently everyone waits out their illness on the weekend and then comes in), will have longer wait times because there are simply more patients waiting to be seen. On that note, many patients who come to the ED, would be much better suited for an urgent care, or even their primary care. Now sometimes it's hard to tell who is truly an emergent case, but I will warn future ED patients that if they come in for a neck strain and other patients are there for potentially life-threatening illnesses, the neck strain will be waiting. Complaining will not get you seen faster if other people are in worse shape, and being disruptive might actually hurt your case because no one likes to deal with unpleasant people. So, when you're in the ED, be patient, and be observant. If there are patients being seen in hallway beds, or you hear a provider mention they haven't eaten or used the bathroom since their shift started, it's probably a busy time and you might be waiting longer. Sorry. Enjoy the free TV and snacks (if you're not NPO, that is). 

     Of course, there are moments in the ER when there's not enough time, moments when you are running because even the seconds count. These moments might not be as frequent as TV would make you believe, but they happen, and they can be terrifying. There were four times on this rotation when I thought a patient's life was in immediate danger. The first time was a young man, a healthy-looking fellow with nothing but a right-sided chest pain that he said he almost didn't come in for because it didn't seem so bad. In fact, his pain didn't seem so bad to us at first either. If you looked through the notes written about him that morning, you would see the same phrase over and over: "no acute distress." This is essentially a description saying that this man did not look sick, and gave no indication that, less than an hour after being brought to his room in the ED, he would need an emergency procedure to save his life. Physical exam however, revealed that the patient had a pneumothorax, also known as a collapsed lung. It can happen for numerous reasons, but in young, tall, thin males, like this patient, it's often a spontaneous occurrence and is not necessarily life-threatening. In fact, some studies recommend that if that the lung is not too collapsed, the patient can be managed conservatively* (i.e. they're allowed to go home and told to return if things become worse, rather than having a chest tube put in to let out the air that has escaped from their lung into their chest) because they'll likely heal on their own. In 1-2% of cases however, spontaneous pneumothoraces can become tension pneumothoraces,** meaning that the air flowing from their lungs into their chest cannot escape and begins putting pressure on the heart and other lung. This is an emergency. In the case of my patient, less than 15 minutes after getting the x-rays back that confirmed his diagnosis, and while thoracic surgery was on the way to the ER to put in a chest tube, his heart rate and blood pressure suddenly plummeted. While the nurse and doctor quickly sterilized and numbed the patient's chest, the PA and I tried to keep him talking so we could gauge his mental status and whether or not we actually had time to hit all the proper steps. I wasn't sure that we did because, as a witness later said, the patient "looked like death" and was struggling to focus and respond. Even as my worry and fear grew, the other providers remained calm, and in what seemed like eternity but was really 2-3 minutes or less, the patient's chest was cleaned, numbed, a needle was inserted between his ribs, and a rush of air came out. His vitals began to stabilize immediately, and he began to talk normally again, telling us that his pain was gone. Shortly afterward the thoracic surgery resident arrived, a chest tube was placed, and x-rays showed that the patient's lung had reinflated. He had to stay at the hospital for a couple days, but he was just fine. Unfortunately, not all my patients had happy endings.

The view on my ride along

     I worked three codes during my overnight shifts. Two were only an hour or so apart. None of them survived. It was the first time I had actually watched a patient die. I'd come close during my last day of my surgery rotation when one of my patients requested to be put on care measures only after contracting an infection, but if she did pass, she did so after I was gone. This was different. The first patient had arrived in the ED in bad shape after an overdose, but still very much alive. Once his lab work came back though, it was clear that he was not a simple case of administering naloxone and observing until better. A lactate level of 4 mmol/L (typically the highest level mentioned in most studies of lactate levels) is 55% sensitive and 91% specific for death in the next 3 days. This patient's level was 15 mmol/L. Within a few hours of arriving, he went into cardiac arrest. I ran into the room, joined the rotation for chest compression, and was shocked at how pale, blue, and still he looked. Minute after minute everyone worked, administering medications, performing compressions, and delivering shocks. Nothing helped. An ultrasound machine was brought in and we paused long enough to stare at his heart as it appeared on the monitor. Nothing moved. We tried a bit longer, but eventually the doctor told me to stop compressions, felt for a pulse, and declared the time of death. The patient's family, who had chosen to stay in the room and watch, were composed and graceful as they thanked us all for doing everything we could and then said their goodbyes. I went back to my desk and stood there, my hands shaking, as I tried to compose myself and process what had just happened. A friendly tech brought me a cup of water and told me I'd done well. When, after a few minutes, I was ready to face other people again, the doctor who'd run the code asked me if I had any questions and kindly walked me through the events of the night. I am so grateful to that tech and that doctor. I needed a bit of kindness and gentleness to get me through the shocks and experiences of that first code, and less than 5-10 minutes was enough time to get me functioning like normal again. It had to be. The ED was packed that night, so there were still more patients to see, and, though I didn't know it at the time, in less than 2 hours I would once again find myself performing CPR. That time it was an elderly woman who'd fallen and hit her head. Though her heart seemed healthy, we lost her as well because we could not fix the damage to her brain. The next night I was part of another code, and, once again, was asked to stop compressions and step back so that a time of death could be called. 
     It sounds sort of horrible to say it, but the codes became easier. Already by the second one I was used to the routine and rhythm and could perform my role without having to continually remind myself to focus on my compressions rather than being distracted by my patient's face. I also learned how to recover. You had to. One can't have a mini-breakdown after each rough case because there's always another patient counting on you. So I learned to get some water and take some deep breaths, as well as pick an easy or pleasant patient to see next, if I had a choice. Letting a 3-year-old with pneumonia play with my stethoscope was a welcome change after hearing agonal breaths, and an injured toe seemed an easy fix after watching a heart monitor show asystole. 
     I don't wish to leave this post on a low note. The truth is that the vast majority of the patients I saw did just fine, and these codes only occurred on my overnight shifts. My fast track shifts were full of sprains, lacerations, and fractures, so I had plenty of practice suturing, stapling, splinting, and performing orthopedic exams. Patients in the pediatric department could pull at your heartstrings, but the good news was that pediatric patients tend to bounce back quickly, and once their diagnosis was determined and treatment was started, the parents often needed more care and reassurance than the patients. Yes, the patients in the main ED on my day time shifts could be serious, and I still wish that I had been wrong the first time I correctly made a complicated diagnosis (a small bowel obstruction caused by an incarcerated hernia in a patient with a massive ovarian tumor), but, for the most part, my patients were treated and returned home to their normal lives. In the end, the lives of me and my patients only intersected briefly, and these encounters could be terrifying or frustrating, but for those hours I had the chance to meet an immediate problem and do something to fix it, and that is a wonderful thing. 

*Light, Richard W. Primary Spontaneous Pneumothorax. In: UpToDate, Polly E Parsons (Ed), UpToDate, Waltham, MA. (Accessed on October 22, 2015.

**Noppen M, De Keukeleire T, Pneumothorax. Respiration 2008;76:121-127

Cut to Cure (23/30)

     Before starting my surgical rotation, I was both very excited, and very nervous. I knew from my time in Kenya that I enjoyed observing and assisting with surgeries, so I was looking forward to the chance to do it again. Plus, it's a rare thing in medicine to be able to cure a patient's problem with one procedure, but this is a real possibility in surgery. If a person's issue is an inflamed and infected appendix, we can just take it out. Boom. Problem solved. However, I knew from my women's health rotation that surgery can also be stressful, and I was all too aware that we had not spent much time covering suturing and surgical knot tying in lab during my didactic years, so I was a bit terrified of screwing something up. I also wasn't too thrilled about the ice box ORs (60 or 62 degrees was the norm) or long days (shifts were could be as short as 8 hours, but typically lasted 12-14 hours, depending on how many operations were scheduled) or all the procedures that hadn't been covered in depth during didactic ("treatment: surgery" doesn't cut it as an answer when you're actually in the surgery),  but I prepared myself to try to learn as fast as possible. There was definitely much to learn.

From Medcomic

     One thing I learned right away on the surgical rotation is that, in surgery, more than in any other of my rotations, the hierarchy and divisions of medicine are clear. As a student (whether PA or MD), you are at the bottom of the totem pole. Above you are attendings, PAs, NPs, residents, interns, nurses, and basically everyone else. When you're actually in the OR, there are even more people, like the anesthesiologist or nurse anesthetist, circulating nurse, and, of course, the scrub tech or scrub nurse (a quick note on the scrub tech/nurse: you do not mess with them. You give their table a wide berth, you follow all their commands, and if they say you broke sterile field, whether or not you think you did, you had better apologize, make it right, and then promise never to do it again. Some scrubs are nice and friendly and will ease you into everything if you seem unsure. Others will watch you for signs of weakness and will put the fear of God into you if they sense you have the potential to screw something up, which is necessary since a patient's life could be on the line. You just have to figure out how to live and learn with both, and focus on doing the best you can do.).  In short, there are a million people who can, and likely will, order you around. That's part of being a student, just like coming in at 5AM to do pre-rounds before actual rounds, or having the freakish 24+ hours overnight shift. Some students hated this, but everyone had to deal with it. 

     Beyond the hierarchy, I also learned to recognize the other divisions in the medical fields, specifically the divisions between providers who chose to go into surgical specialties, and those who chose to go into medical (aka non-surgical) specialties. Anyone who has watched the TV show "Scrubs" knows that the surgical people (typically portrayed in green scrubs) are known as the jocks, and the medical people (typically portrayed in blue scrubs) are known as the nerds. This is a stereotype actually perpetuated in real life as many of the surgeons would jokingly refer to themselves as "dumb surgeons" who just knew how to take things out of people. Obviously, this was a gross misrepresentation, but it was funny to actually hear them say it. It was even funnier to hear the general surgeons talk about the orthopedic surgeons, because the general surgeons often referred to their compatriots in orthopedics as being the true "jocks" of medicine. However, I will admit that it is true that orthopedic surgery is in a different class from general surgery.

The Todd... jock surgeon extraordinaire

Orthopedic surgery sometimes felt like a workout as I stood there holding up a limb for what seemed like an interminable time (fact: unless you look like a pathetic weakling, this is the student's job and, fact: whether it's an arm or a leg, they get very heavy, very quickly, especially when you can only support them with one hand lest you accidentally touch a sterile area while not yet scrubbed in yourself), and it is also more violent then general surgery. There is truly elegance to any surgery, and sometimes I loved simply watching the surgeons as they deftly made incisions, tied off vessels, etc., all while making it seem like a dance. The dance is just rougher in orthopedic surgery. It's hard not to be when a typical set up for an orthopedic procedure includes mallets and saws. Yes. Mallets and saws. I enjoyed scrubbing in for any surgery, but I am not sure I'll go into orthopedic surgery in the future as I have learned that the sound of bone crunching kind of freaks me out. Go figure. 

Expressed calcium deposit.
Image can be found here.

     In case I wasn't sure before, this rotation reminded me that it's ok to have fun in surgery. I could give multiple examples of this, but the one that comes to mind right now is from my time in orthopedic surgery. There was a patient with shoulder pain because calcium deposits had built up in the tendons of their rotator cuff, and they needed to be removed. We did that by inserting a camera, finding the deposits, making a small hole, expressing (aka squeezing out) the deposits, and then stitching up the hole. It turned out that this procedure is surprisingly satisfying and entertaining. This might weird some people out, but it's a bit like squeezing a zit, only you're squeezing out calcium deposits (which can either be hard as a rock or more like toothpaste) rather than pus, and there's much more to squeeze out. During the surgery I observed, nurses from other rooms came to tell my room to quiet down because everyone was laughing too much and getting too excited whenever we found another deposit. It was very, very weird, yet also very fun. I guess you could say I learned to embrace the weirdness. 

The coffees of my overnight shift

     I talked in a previous post about how much of clinical rotations is just learning to be flexible. This is another part of the weirdness, especially as you have to learn to handle a schedule that changes daily. My schedule for this rotation was divided into four sections, each lasting just over a week. These sections were general surgery (primarily gastrointestinal surgeries, each time with a different surgeon), orthopedic surgery (we found out our assigned surgeries in the morning on the way to the OR), orthopedic office (each day was spent seeing patients in the office of a different orthopedic surgeon), and general surgery office, which I actually spent in the weight loss clinic. This last section involved the unexpected realization that there's quite a bit of psychiatry in surgery, at least in bariatric surgery. I'm not sure about other weight loss clinics, but if someone wanted to have bariatric surgery done at my site, they were required to meet not just with the surgeon, but also with a nutritionist/dietician and psychiatric nurse, as well as attend meetings held by other people who had undergone the surgery. The goal was to make sure that the surgical candidates were really prepared for the operation, that they understood what life changes the operation required, and that they would actually be able to stick to those changes. I learned that it is possible for someone to "fail" a gastric bypass or gastric sleeve (i.e. still gain weight), and that there were good indicators of who those patients would be. Specifically, any patient suffering from an uncontrolled psychiatric illness was told to wait on their operation until they were mentally healthy, patients who had been obese since childhood did worse, and patients were reminded over and over how important it was that their family supported their decision since the lack of encouragement (or even downright enabling of bad habits) from family members was often a major deciding factor in whether or not a bariatric surgery had the desired long-term effects. On that note, patients were also counseled that their family not only had an effect on them, but that they also had an effect on their families. Overweight parents in particular were reminded that much (some might even argue most or all) of a person's future eating habits are set by the time they turn 8, and thus the importance of developing healthy eating habits in children could not be overemphasized. If you want to see a video that makes this point in a vivid way, I present this ad: 

     On the subject of making life choices, I should mention that I was tempted to title this post "Lose Weight, Stop Smoking, and Exercise: Primary Care Part 2" because it seemed like much of my rotation was simply spent dealing with the consequences of people ignoring the advice of their primary care doctors. Orthopedic surgeons would lose much of their business if people were not carrying around extra weight that wore and pounded on their joints. Cardiac surgeons would have less to do if people exercised and kept their hearts fit. All surgeons would have easier jobs if people just stopped smoking because (contrary to the popular notion that smoking just affects your lungs) smoking affects every organ system in the body. I have a post on smoking in the works because it comes up so frequently, but right now I'd like to mention one aspect of smoking closely tied to this rotation: there are surgeons who will refuse to perform surgery on a smoker, and they have good reason for this. Smoking causes narrowing of the small blood vessels all throughout the body (vasoconstriction), which means that those vessels are no longer delivering much needed nutrients and oxygen. After a surgery, this can mean an increase in both healing times and failure rates for the procedures. Now if a patient comes in with acute appendicitis and they need an appendectomy before the appendix ruptures, of course they will get the surgery, whether or not they are a smoker. For more elective or less emergent procedures though, there's a good chance that surgeons will require that patients quit before they'll operate. Orthopedic, cosmetic, and bariatric surgeons in particular are strict about this, and some will even test their patients for nicotine before the operation to ensure that the patient has been compliant. So please, just quit smoking now. Soapbox over (for now).

Some advice for PA students preparing for their surgical rotation:

Knot tying on my overnight.

• Sometimes residents bribe you with chips and a cookie to stay late and assist with a surgery. This is completely ok. Take the food and eat it while you can.
• This follows the last point, but please eat. You might have very weird hours, but grab at least a snack, even if it isn't a full meal, between surgeries because you do not want to pass out in the middle of a surgery. That being said, if you do feel light-headed in the OR, tell someone ASAP.
• If you know ahead of time what surgeries you'll be assisting with, look them up the night before and become very familiar with the anatomy you'll be seeing. 
• Practice your suturing and knot-tying whenever you can. Keep string on your keys, your steering wheel, your scrubs, wherever. 
• Be flexible. Different rotations are set up differently, but chances are good that there will be a lot of uncertainty. You might work with a different surgeon each day (or even each case), or surgeries might run late or be added on, or complications might arise intraoperatively. No matter what happens, you have to be prepared to roll with it.
• Embrace the experience. Even if you hate surgery, this might be your only chance to actually see the inside of a person while they're still alive, or to cure a problem with a single procedure. You can acknowledge the difficult aspects of the rotation, but take time to recognize the incredible things you are witnessing and enjoy them. 
• Always go with your patient to the recovery room. You should also introduce yourself to them before procedures.
• Realize that sometimes you will feel like an idiot. Some surgeons are jerks. Some residents enjoy hazing. Sometimes people just don't explain everything and yes, there really is a purpose to you rubbing a woman's breast for 5 minutes while everyone else leaves.* You just have to do your best, ask questions when you don't understand, and not let the jerks get to you. 
• Surgeons like to quote the saying, "all bleeding stops eventually." This is 100% true. It is also 100% terrifying. Bodies are complicated, and everyone is a bit different, so chances are good that, no matter how careful everyone is, at some point during your surgical rotation an artery or vein will accidentally be nicked. The most important thing is to remain calm. If you can take a deep breath and continue retracting, or whatever it is you are supposed to do, this will allow the surgeon to find and fix the bleeding vessel that much sooner, and a crisis can be averted. 

Elf ears happen

• Surgical caps can make your ears point out and turn you into an elf. Deal with that, or settle for the silly bouffant. It's your choice.
• Keep the safety of the patient foremost. If a patient has a penicillin allergy, yet you hear the anesthesiologist say they're going to give prophylactic cefazolin, speak up. You might have misunderstood about the patient's allergy, or the anesthesiologist might have missed it, but no one will fault you for double-checking, especially if you do it respectfully. You should also make sure the patient is safe on the operating table, especially in the times right before and after the procedure when they're half-conscious and possibly not always surrounded by nurses and doctors. I saw big patients who we had to make sure didn't drop or roll off the table, and I helped with another patient who tried to fight his way off the table as the anesthesia was wearing off. 
• Know GI! My rotation was predominantly GI and ortho, and I think that's pretty typical. Any neurosurgery usually has to be done as an elective, OB/GYN surgery is saved for the women's health rotation, and most thoracic surgery is reserved for students who know that's what they want to go into, so it's not typically an option for the general clinical year.
• Enjoy the scrubs. Scrubs are basically professional pajamas and they are wonderful. Your surgery (and possibly ED) rotation might be the only time you get to wear scrubs during the clinical year, and you might never wear them again unless you go into surgery or emergency medicine, so enjoy them while you can. 

     In case anyone is still bummed by the dire consequences of poor eating* or smoking (and also just because I love Scrubs), I have decided to close this post with this cheerful gif and video compilation to celebrate the beautiful friendship that is JD and Turk.

via GIPHY

*I had to do this before a breast lumpectomy and biopsy. The resident had injected blue dye that we hoped would drain to the sentinel lymph node so we'd know which node to remove. Even though I was pretty sure I knew why I was doing it and that it was actually an important part of the procedure, it still felt very weird to be massaging an unconscious woman's breast while everyone else left the room to scrub in. 

*When we talked to patients about simple ways to lose weight, the doctor I was with always shared the same four principles: 1. Don't drink your calories (i.e. cut out sodas, iced coffees, cocktails, etc.). 2. Have protein in all your meals and eat it first. 3. Don't eat processed foods (i.e. go for whole foods and avoid junk foods, even the healthy-sounding crackers). 4. Don't skip meals. Another thing that also came up all the time was that exercise is great for improving the health of your body as a whole, but the deciding factor in losing weight is simply eating fewer calories. In fact, many times people GAIN weight when they exercise, not because (as so many people believe) they are gaining muscle, but because they use their exercise to justify eating more, and they end up consuming more calories than they burned. The more you know.

Learning to Be Flexible (21/30)

Alarms for my week of general surgery

     When you start clinical rotations, you’re prepared (at least in theory) for certain difficulties. You don’t know your schedule ahead of time, though you know that it will change every five weeks, the emergency medicine rotation will likely have odd hours, and you will probably have to wake up very early for the surgery rotation. You’re told that you will likely feel like you know nothing at first and that any time not actually spent at your rotation site will probably be consumed by studying. You know that some rotations will be better than others, but that even the worst ones will end. Then the first day comes, you take a deep breath, and you step into a new realm of uncertainty. It’s not just for the first rotation either; each rotation is different from the last and while you may quiz your peers on what to expect, you still face each first day of each rotation with a blank slate and lots of questions. What does your preceptor expect from you? What are the typical hours? Are there typical hours? Will I be quizzed constantly? What will the other students be like? Will patients refuse to be seen by me? What if I completely botch a procedure? What if I forget all the medications I ever learned? And on, and on, and on... The truth is, the questions never really stop, they just change into new questions. By the time you finally start to feel comfortable at one rotation, time’s up and it’s time to go some place new.

Before going into an appendectomy at 11 AM, and then later at
midnight, with at least 7 hours still left to my overnight shift.

     The key to keeping sane sometimes is to just be flexible. Some rotations will never give you a clearly defined schedule and you just have to live day by day. For some rotations your preceptor changes daily, so you’re constantly adjusting to new and different personalities. For some rotations you realize that the experience of your peers might vary vastly from yours, sometimes based on what seem like tiny details. For example, I am currently on my surgical rotation, which includes an overnight shift during the week of general surgery. The thing is, because I’m in general surgery first, my “week” is actually one day longer than the other weeks of this rotation, so there is a definite possibility that I may have to do one more overnight shift tomorrow, even though I already did one last week. I will admit right now that I am not thrilled about this prospect, particularly since the “overnight” shift actually goes from pre-rounds (5 AM) of one day to post-rounds (approx. 7:30 AM) of the next and sleeping rarely happens, but if it has to happen, it has to happen. Rolling with the punches and adjusting expectations is just part of the clinical year. 
     I’ll probably do a post in the future about some of the other difficulties of the clinical year that don’t often get discussed (What if your preceptor is a bad teacher, or worse, a bad clinician? What if the preceptor for your next rotation decides to reture? What about all the non-rotation related things that can cause problems, like cars or living situations?), but right now I need to grab some lunch, read up on laparoscopic cholecystectomies, and attempt to get the electricity account transferred from one roommate to the next, so it's time for me to sign off.

UPDATE: a kind medical student volunteered to take the overnight shift so I didn't have to do another one. It was only later that the chief resident informed us that a student wasn't necessary for every overnight shift anyway.