Internal Medicine is OVER!!

A synopsis of my 2 month rotation of Internal Medicine:

 

I enjoyed most of Internal Medicine. I loved admitting an acutely ill patient, asking them questions, getting to reassure them, then actually making them feel better. It's amazing what a diuretic pill can do for someone. Or a thoracentesis. Or just having a hand to hold when they get a hard diagnosis.

I also enjoyed working with a team: getting to see how each person handles a variety of situations from sleep deprivation, to caring for "difficult" patients, to devastating diagnoses. I learned valuable lessons from my attending physicians, residents, interns, and even other students. I learned that sometimes, to get something done, an attending has to clip someone's finger nails. I learned that it is possible to work for 30 straight hours and still have energy to work hard. I learned how to study when I really had no energy to. I learned fun mnemonics and ways to remember clinical information. And I learned the occasional, random but helpful, fact.

One of my favorite parts of this rotation was sticking a needle into someone's stomach and taking out 10 liters of fluid. I also loved being the sole advocate for a "difficult" patient, Mr. C, who spent 3 weeks on our service. He had an anoxic brain injury and no caregiver could be found, so we started the process of applying for state guardianship. I helped coordinate that process, helped fight for him to be treated better by the nursing staff, and helped fight for better control of his glucose.

Working at a major medical center, we had so many resources at our fingers, and yet, sometimes we still didn't have what we needed to care for our patients. We had the ability to get everyone physical therapy, but we had a hard time getting people who didn't qualify for dialysis off of "compassionate dialysis" and we had a hard time fighting for the rights of some of our patients who had no one else to speak for them.

After being on internal medicine for about a month, I saw a few patients I had seen before, and it was fun to have credibility with them, and with my interns as a capable note writer!

I learned so much from this rotation. I feel like I can talk more like a doctor now! I learned reference ranges on most lab values, I learned typical drugs ordered for inpatients, and how to pull Evidence Based Medicine (EBM) into patient care. My first month we had a librarian that would round with us twice a week and look up articles about patient care issues we talked about and then send our team the articles. It helped us to make better clinical decisions and it showed me how using EBM can benefit patients.

I got to practice my Spanish, and by the end of the rotation I was able to talk with patients and help my team translate a quick message or a full H&P.

I also learned that I CAN work 30 hours in a row and survive (just barely). And I'm so thankful that I will never have to again!!

Pictures

First day of Internal Medicine (sorry for the bad quality photos!)

 That's a better face shot of the first day (it was early and dark...)

 My Scrubby Puppy Baby!

 One night when I was on call...I look like I'm SO over it at this point...

Family Skype time!!

 The view from the room across from my first call room.  My first call room had no windows.

My Team mate, Nate, who bought one of his patients breakfast when we went to buy coffee.  How thoughtful!

Early morning or late night? Either way check out the darkness outside and the city lights :)

My Patients, My life

I've been taking care of a lot of patients lately. Working 60-90 hour weeks in the hospital and trying to study.

But I've decided I need to get myself a pair of white gloves. More like mittens actually. Check them out at the site below.

http://www.psychosomatic-medicine.com/vitality-medical/product-details/POS2816.html

The vast majority of my patients at one time were wearing them.



One of my most memorable patients was Mr. C. He was admitted to my service about a week into my rotation. I really had no idea how to handle patients at this point, let alone a patient with an altered mental status and aggression.

When he came in, his chief complaint was altered mental status and aggression.  Great, I'm not sure I've read any book or had any lectures about how to deal with aggression as an inpatient on a medical ward.  That's all the information we had on him.  When we went to do a History & Physical, we quickly realized that that was all of the information we were going to get.  We were unable to get a response out of the patient at all.  His eyes were open, but he wasn't moving much.  We were able to do a decent physical exam: (a bunch of "doctor talk , you can ignore this if you're reading my blog…) heart rrr, no mrg, lungs ctab, skin covered in lesions that looked self inflicted with his cm long fingernails.  extremities severely wasted.  lines included a picc line, femoral line (apparantly placed by the ER before they saw the picc because they couldn't get peripheral access, ridiculous), a g tube, and something else.


The only response we were able to get out of him was a sharp "STOP" when trying to elicit a babinski reflex.  Which scared me half to death.


We called the nursing home he came from to try and get more information.  They had him for a grand total of 21 hours and really were of no help as to his Past Medical History.  Both numbers listed for family (a mother) were incorrect. Great.  So we called JPS hospital in Fort Worth, who had taken care of him previous to his short stay at the Skilled Nursing Facility/ Nursing Home. 
 
And they were able to fax me a huge packet of information to sift through.  Oh, fun.  Upon examination of the packet, he had suffered from an anoxic prain injury some unknown time in the past, and was only A&O x 1.5 on a good day. (meaning he only knew who he was, not where he was or what the date was)  He also had T1DM (type 1 diabetes mellitus) and a seizure disorder.  As well as ESRD (end stage renal disease: broken kidneys which means he was on dialysis) and GERD (Gastro Esophageal Reflux Disease, or heartburn), at the tender age of 32.


His name, we learned, was Mr. C.  After correcting his electrolytes (blood salts) and hypoglycemia (low blood sugar), he was able to sit in bed with a 1:1 (a person paid to sit with him and watch him all day).  He was also, shockingly, able to walk with PT (physical therapy) and eat with assistance.  I would have never guessed!  He still remained, largely, a mystery to the team.


And so, another call cycle came and went and he sat there.  We were working with the endocrine consult service to control his blood sugars.  They ranged from less than 40 to over 600 (normal is 80-120).  His other medical problems had long since resolved.  He fluxuated up and down despite changing control of his lantis and aspart (insulin given to drop his blood sugars)...and on and off glargine (another insulin)...and on and off D5/ Glucose to correct for hypoglycemic (low blood sugar) episodes.


One of our fist tasks was to clip his nails.  They were dangerous to him and other people.  But apparently the nurses at Parkland are "too good for that job." Honestly?! Whatever. So, instead of passing the task off, our Attending got washable nail clippers from her Nurse Practitioner and cut them herself.  That made me respect her SO much!


We tried to take him out of restraints, but the nurses and1:1 sitters were impatient with him, which frustrated me.  All he wanted to do was walk up and down the hallway...but they were afraid of him.  He even had those great mittens to keep him from scratching himself or another person.  I mean, why have a 1:1 sitter if they won't help the patient?! Restraints just make someone more agitated!  (something my attending taught us, which was another great learning lesson)


I was tired of him being here because a lot of people, most of the nurses and staff, thought he was difficult and insisted on keeping him in restraints because he occasionally called out "help me."  when he wanted to walk around.  I think I would too if I were strapped to a bed all day! But he was so easily directable with guidance. If you took the time to guide him.  Which I did (and I'm not that skilled!) but most other people never took the initiative to do!


He was THAT patient I had that was just there, each day we would hope to better control his blood sugars, and each day they either ranged dangerously high or low.
 
He went to dialysis Monday, Wednesday, and Friday.  I usually missed seeing him those mornings.


Then, after having him in my care for almost 3 weeks, the endocrine consult service  put him back on an insulin schedule they had already tried and failed. What?! So I talked to my resident, but instead of jumping in to save the day, she had me call the endocrine fellow.  So I did. At this point, people on my team had given up on ever getting him under control.


So, after talking with the endocrine fellow, she agreed to talk to her attending about better managing him.  And then I talked to the Pharm Ds (people who got their PhD in Pharmacology, the study of drugs).  Brilliant people.  They came up with a new plan: keep him on short acting to see what he needs, and then make a long acting schedule, that works with his dialysis schedule.


After another long week his blood sugars were under better control.  Not perfect, but workable.  Nothing that would get him sent right back to the hospital!  We made his chart nice and organized so information would be easy to find on him if he was ever admitted again.


One day right before he left, I was able to have a good conversation with him.  He told me he liked be called A, instead of "Mr. C"  He told me where he was (almost) and I helped to explain to him why he was there.  He always smiled when I walked into the room.


I left the service and started a new rotation before he left.  And wouldn't you know, I was on a completely different team based on a completely different floor, but one of the new patients I was assigned was an elderly man with Altered Mental Status (delerium!) who was A's roommate.  So I still got to check up on A.  And I was happy to see him doing much better, and finally make his way back to a Skilled Nursing Facility.


I helped someone.  I fought when no one else wanted to!



 
But then last time I was on call, my intern got a page on a cross-cover patient. (the team on call takes care of all the other teams' patients plus admitting their own patients on call night…it's a bit crazy!) I recognized the name, and so I went with him to see if we could talk to him instead of just slamming him with more drugs. Which we did. It was heartbreaking to see him in the hospital again, and to learn that he had already been admitted and let go of earlier that week. So much for fighting. I don't know what's going to happen to him now.



Since them my patients have come and gone in themes:

Congestive Heart Failure

Cirrhosis (dead livers, which there is no treatment for) with big bellies full of fluid, which they let me drain off with a big needle…SO cool!!

AMS/ Agression/ Delerium

HIV/AIDS


 
Thankfully, I'm almost done with my 2 months of crazy Parkland wards and being at the hospital 30 hours every 5 days plus 10 hours on normal days. I'm ready to sleep again, but not ready for our test at the end of the rotation…

Internal Medicine

The best word to describe internal medicine is intense. Everything about it: the hours, the learning curve, the expectations, the patients. Nothing has been super easy (except eating the free lunches we get Mon, Tues, Thurs, and Fri!)

Some of the hard things I've faced:

1. Working hard from 7 am to noon…noon the NEXT day, with no sleep in between. 30 hours is rough!!
   
2. Telling a man who only had 1 month of symptoms that he has metastatic pancreatic cancer and his prognosis is poor…like max 3 months to live. Sad. Hard. He asked "What do I do with my life now?" What do you tell a guy like that?!
   
3. Falling asleep in front of my attending…oops!
   
4. Trying to stay awake at 3 am when nothing is going on…but you can't sleep because your team hasn't capped (gotten our max number of patients for the night) yet.
   
5. Remembering everything I'm supposed to! (or learning it for the first time!)
   

Some of the fun things:

1. Watching the sun rise, set, and rise again all in 1 shift of work.
   
2. Hanging out with my med students!
   
3. Lunch!
   
4. Learning a lot!!
   

I'm on call again tomorrow night. I'm not sure how 4 nights of sleep went by so quickly, but I have a new attending doctor, and I hope to get more sleep!

 

Surgery Synopsis

Surgery is over. I enjoyed it, but I'm glad it's over.

I was on vascular surgery at Parkland. A typical week would start out at about 4:45 on Monday morning. I would pre-round on my patients and make a sheet for my residents and attending with all the vital signs of all our patients. Then we would round with the residents and then with the fellow. After rounding with the fellow, sometimes we had 15 minutes to grab breakfast and run to clinic.

Clinic was always chaotic. There were 6 students, 4 residents, 1 fellow, and 1 attending in clinic. The students saw patents, presented them to someone more qualified, and then wrote a note. It was interesting to follow up on patients that had previous surgeries and see how it looked to care for a patient that was a few weeks post op. I got to take out some staples and look at some fresh amputations.

I feel like we did a lot of that in vascular surgery. If we couldn't reestablish blood flow, we would cut someone's leg off. Sad, but I guess it's what has to happen.

I also got to look at how a pre-op history and physical exam works. I figured out all the "important" H&P questions that the attending really needs to make sure you ask and document: "Are you taking any ASA or blood thinners?" "Have you had recent chest pain/ trouble breathing?" Etc.

And I got REALLY proficient at finding someone's pulses, either with my fingers or with a Doppler, which is an ultrasound wave you can hear. I learned to differentiate between triphasic, biphasic, and monophasic pulses. I began to recognize the difference between arterial and venous problems. And the plan to treat people with those problems. I also got good at using the electronic medical records system. It took a while to figure out where everything was, and I had to ask a lot of questions, but eventually it became pretty easy.

After clinic on Monday, we would all eat lunch in the cafeteria with our attending doctor and he would lecture us on a vascular issue. I loved listening to him, because he was so knowledgeable and he would tell us everything and then let us ask questions.

Most other days we pre-rounded, rounded, and went to watch a surgery. Or went to watch a surgery get cancelled. I scrubbed in to 2 cases. I got to watch a few more from the OR, but with 3 students and 1 attending, it was hard to have enough to scrub in to.

Wednesdays were fun. We had lecture from 7 am to noon, then lunch. I got to work in small groups with med students for 2 sessions each morning and we discussed practice patients. I enjoyed getting to talk through patients. I felt like I learned a lot! I also got to work with Dr. McClellen and have tutorial sessions with him on Wednesday and Friday afternoons. We would each present a topic and then talk through it with our group. He had a lot of wisdom to share with us.

My fist surgery was lame. It was endovascular, so I got to watch them stick wires up a man's groin to his carotid artery. I didn't touch anything. It was neat to wear lead and watch the screen to see where the wires were going. I liked getting to read about a procedure before and then see it in action.

2^nd scrub: intimidating. Still not sure exactly what to do. Or even really why scrubbing is SO important if we rinse our hands in non-sterile water and then put them inside of 2 layers of sterile gloves. It was a lot cooler. They cut the patient's whole stomach open and made 2 cuts in each groin. They let me stick my hand up one of the groin cuts into her abdomen. It was neat to feel the inside of someone! I liked getting to watch them cut and then sew in a graft to the aorta and then connect it to her femoral artery. My favorite part was watching the graft pulsate when they let blood flow through it! They let me staple the woman's abdomen. I need a bit more practice with staples before I'm good enough at it!

Coolest thing: Getting to be part of a patient care team. Being asked to change wound dressings and using that time to make sure the patient didn't have any questions and answering them when they did. Gettting to watch the patient's face when the resident "explained" something, and then going back to see the patient and spending time to actually make sure that they understood what the resident was talking about earlier and they were too scared to ask questions about.

I liked getting to work on a team and be a part of something. Working with Med students, doctors, nurses, PT and OT, I really got to see how a patient moved from a clinic appointment, to surgery, then to another clinic appointment where their problems were resolved.

I liked surgery, but I don't think it is what I want to do. The OR is too high stress. And So disconnected from patient contact. Most procedures your patient is asleep for!

Weekend Shifts.

Chill.

No Surgeries. (not that we do many surgeries during the week)

Now I'm getting ready for the last 1.5 weeks, our 2nd Attending comes back into town so we should see some more cases.  Hopefully.  :)

Weekends are too short.

Ten

Ten people rounded yesterday:
1 attending
1 fellow
1 resident (3rd year)
1 intern (1st year)
1 Sub-I (4th year med student)
3 MS 3s
2 PAs

That's a lot of people to cram in one room for rounds.  Or at one lunch table for an info session about chronic limb ischemia.

Scrubbing In!

So I got to scrub in today. On a carotid stent placement.

After peeling myself out of bed at 4 am (I've been having this internal debate: is 4 am still night, or is it morning? Because clearly, 5 am is morning. Sometimes people wake up at 5 am. And clearly 3 am is still night. I've been out partying at 3 before. But 4 is an in-between. A no-man's land. Unless you're a surgical student/ intern.) I got to the hospital and rounded on my patients.

Then rounded again with the intern. Then again (quickly) with the fellow. Then I followed the fellow to the OR to surgery. The MS3 and Sub I (*See The Hierarchy of Medicine, at the end) let me scrub in because I never had before. And I was pretty excited.

Beyond excited, really J

First, I grabbed gloves and handed them to the scrub nurse. Then I got dressed up in a led vest/skirt combo. Everyone in the room had to wear one since we were doing a procedure where we would be shooting a lot of x-rays in the air. They were heavy, but I thought they looked cute. I wish I had a picture to explain them better. Here's one I found on the internet. Ours were like the turquoise one. Except they were black, blue, or green. All I kept thinking was that they would make a cute dress.



Since I had never scrubbed in before I followed the Fellow around and scrubbed with him. "Scrubbing in" is basically just where you wash your hands and arms really well. Then you be VERY careful not to touch anything and move into the OR. The scrub nurse helps you into an operating gown and then into your gloves. I wore 2 pairs of gloves, but my attending/fellow only wore one. Maybe because it wasn't a big procedure. I'm not sure.

But picture it like Grey's Anatomy: you have on your scrub hat and mask, then wash your hands (for a long time), then hold your arms out and in front of you because they're now sterile. Except we didn't look nearly as cute. Again, I wish I had pictures.

Since we wore masks, you could only really see anyone's eyes. I found it really interesting that eyes could say so much! The nurse (not the scrub nurse, the other one that was running for supplies) and I had total conversations with her eyes. She was sweet. She was about the only one who cared that it was my first surgery so she kept checking on me to see if I was ok.

We were placing a stent in someone's carotid artery (the big artery in your neck) but going in from the femoral artery (the big artery in your groin). Basically, the surgeons kept putting wires and tubes into the patient's groin and taking x-ray pictures to see where in the body they were until they got the wires up to the neck.

At the beginning of surgery all I really did was help hold wires for the surgeons. I didn't even help hand things to and from the scrub table (the scrub nurse wasn't very nice to students) I got pretty good at it. But towards the end of surgery the patient was trying to reach up and grab the guidewires (they don't put people under because they are usually high risk of an acute event like a heart attack or stroke), so I got to hold his hand. I think that made him feel better.

I did a lot of watching wires moving in and out of our patient. I didn't really count, and I didn't know about the procedure to do research in advance, but doing research after, it looks like this:

1. Access into the femoral artery in the leg (or, less commonly, into the radial artery or brachial artery in the arm) is created by a device called an "introducer needle". This procedure is often termed percutaneous access.
2. Once access into the artery is gained, a "sheath introducer" is placed in the opening to keep the artery open and control bleeding.
3. Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is pushed. The tip of the guiding catheter is placed at the mouth of the coronary artery. The guiding catheter also allows for radiopaque dyes (usually iodine based) to be injected into the coronary artery, so that the disease state and location can be readily assessed using real time x-ray visualization.
4. During the x-ray visualization, the cardiologist estimates the size of the coronary artery and selects the type of balloon catheter and coronary guidewire that will be used during the case. Heparin (a "blood thinner" or medicine used to prevent the formation of clots) is given to maintain blood flow.
5. The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible tip, is inserted through the guiding catheter and into the coronary artery. While visualizing again by real-time x-ray imaging, the cardiologist guides the wire through the coronary artery to the site of the stenosis or blockage. The tip of the wire is then passed across the blockage. The cardiologist controls the movement and direction of the guide wire by gently manipulating the end that sits outside the patient through twisting of the guidewire.
6. While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of the angioplasty or balloon catheter is hollow and is then inserted at the back of the guidewire—thus the guidewire is now inside of the angioplasty catheter. The angioplasty catheter is gently pushed forward, until the deflated balloon is inside of the blockage.
7. The balloon is then inflated, and it compresses the atheromatous plaque and stretches the artery wall to expand.
8. If an expandable wire mesh tube (stent) was on the balloon, then the stent will be implanted (left behind) to support the new stretched open position of the artery from the inside.^[11]
   

(Wikipedia: Percutaneous Intervention: PCI)

We also had a close call today: The patient sat up in surgery (we don't put the people all the way to sleep) and he knocked something our of place, causing a clot to move into his brain.  Thankfully, the neurosurgeons came quickly, we got the clot broken up, and life went back to ok.  The neurosurgeon had a really cute lead outfit, it made me smile :)



The Short Version of Today:

I got to wear a lead vest, 2 pairs of gloves, and a gown only to stand and watch as they passed a bunch of tubes and wires up to this guy's neck through his groin. It was slightly anticlimactic. Maybe I'll get to scrub in on a more exciting surgery in the future.





I also got to do a vascular consult on a sweet old lady who had some leg ulcers. I expected her to be larger, have diabetes and a bunch of other medical problems, but she wasn't. She had no past medical or surgical history. Or family history. But her leg ulcers were SO bad. She was showing her achillies tendon and bone on one ankle. After I examined her, I reported her to my intern and fellow, and then they went to see her. And my fellow abruptly told her amputation was the best option. He wasn't mean, just sudden.

When I went back she was clearly upset. It was too abrupt. She wasn't ready to let go of it yet. She wasn't ready to picture how her life would look without it. It made me almost cry thinking about things I've let go of suddenly. It's not fun. Or fair, but life isn't fair.

I realized today how quickly things can be gone. How we can't hold anything secure. Not the ability to speak, like in my surgery case, not limbs, not people. But life goes on, and we learn to adjust. Even if it does take a while and make us upset every now and then.





*The Hierarchy of Medicine:

Attending Physician: What you see on Grey's Anatomy, essentially (Slone, Sheppard, Hunt, Etc.)

Fellow: A doctor who finished residency and is now doing extensive studying in something (not all specialties have fellows)

Resident: 2^nd/3^rd/4^th year after graduation from Medical school. Essentially, they're still learning a bit, but they get paid now. And they have a lot of responsibility.

Intern: 1^st year resident, who essentially, has it pretty bad. I think they sleep less than I do.

Med Student 4 (MS4)/ Sub-Intern (Sub I): They have a bit more freedom than MS3s and PA-Ss do. They get to do more fun rotations and stuff.

Med Student 3 (MS3)/ Physician Assistant Student (PA-S): we sit on the bottom of the totem pole and do all the "scutt work." So they sometimes refer to us as "scuttpuppies." We get all the labs, write notes, and report to the millions above us.

Surgery

Surgery: Day 1.

Honestly, I had no clue what was going on. I arrived at 7 am (thanks to my roommate showing me where to go, because I had no clue where the "crossroads" on floor 2 of Parkland Hospital was.

The Med Student and I stood around waiting for our Intern to come pick us up and show us where to go. We waited more than half an hour, but the he finally came. We went to see a patient. Then to clinic.

Clinic was mostly follow up patients who had some kind of vascular surgery before. But we had a really confusing Electronic Medical Records (EMR) system that my head was spinning trying to figure out. How do you see a vascular patient? Is it the same? Which of the 5 vascular surgery students (my teammate and I were working with the vascular surgery students from St. Paul Hospital) gets to see the first one? What is going on?!

The med student went to see a patient, and we only had one, so I went with her. Because I wasn't sure what to do with the EMR system. And I wasn't sure I knew what to do. But after watching her, I felt much better (and more confident: I CAN do this, I have been doing this, and we don't really need to use the EMR to see the patient.) Sweet.

Then we rounded with the St. Paul students and our Attending, so there were 8 of us walking around (attending, resident, intern (an intern is a 1^st year resident), and the 5 medical stundents) Then we all had lunch with our attending and learned about Acute Vascular Insufficiency.

Some random facts about Acute Vascular Insufficiency (I was the only one who didn't take notes, so I wanted to write it down before I forgot, to help me learn it. Really, you don't have to read this): When a vessel (artery or vein) gets occluded from a thrombus. Clinical Presentation is 6 Ps: Pulselessness, Paresthesia, Poikilothermic (cold), Pale, Paralysis, Painful. Things to order: CBC, CMP, EKG, etc. Also ask a good history to help you find out what the cause of the thrombus was. There are a few different categories. I know 1, 2A, and 2B are the ones you consider therapy for. (3 is basically a dead limb, so you have to amputate.) You give everyone Heparin as a 80-100 mEq/kg loading dose and then 18 mEq/kg per hour. Then you consider tPA, which would break up the thrombus. There are a few contraindications to tPA: disease > 14 days, bleeding (trauma, recent surgery, stroke), etc.

After lunch, we learned a few more things, and went to research our case for tomorrow. Our 3^rd year Resident made us look for an article on Fenestrated EVAR (which is a fancy kind of aneurysm repair, it's pretty new). Only, we spent about 45 minutes looking for it on OVID, PubMed, and even Google before we gave up and emailed him. We read a few other articles along the way (which is why he made us research it…)

So, tomorrow I'm looking forward to scrubbing in on an 8ish hour surgery! I'll let you know how it goes "scrubbing in!" (and how it goes getting to the hospital before the world wakes up: 4:30 am...I might as well sleep there!)

Deuces

Today was a day of "2s."

2 lacs to fix
2 UTI patients
2 or 3 abscess rechecks (I'd never done one before today!)
2nd day working with the same preceptor

But it was also a day of lasts

Last day in the ER!!
Last "emergency" to take care of
Last time to look at an abscess (or HSV) for a while...

Sweet :)

Night Shift

"When everybody else is getting out of bed
I'm usually getting in it
I'm not in it to win it
I'm in it for you"

Train. "If It's Love"


My first night working in the ER was fun. It was SO strange waking up late and going to work at 6 pm when my roommate/ the rest of the world was coming home. I hit SO much traffic getting through Dallas, yuck!

Highlights of the night:

Taking care of a cute 5 year old who "my head hurt so bad that it made me cry on the bus ride home." Awwww….poor kid. He had a fever and sore throat. I had no idea how the headache fit in though. But my preceptor told me little kids don't know how to say headache. But their head hurts when they have a fever. We checked him for meningitis, and there were no signs, so we treated him for his sore throat. He was such a good sport about us looking in his ears and throat. I was so impressed by the way, even though he was obviously not feeling good, he sad up and let me listen to his heart and lungs. I told him he was such a great, big boy.

His mom told me I must have kids.

When I told her, no not yet, she said, "but you should have kids, you're really good with them!"

Which made me smile, and say, "maybe one day, but not anytime soon." And walk out of the room feeling better about being able to examine kids.

My preceptor also told me I was doing a great job. She told me I had skills that she hadn't seen in some of her students getting ready to graduate, and she was really impressed by me. Sweet. Maybe I am learning a little bit!.

……………….

Night 2 I worked with the same preceptor. She gave me a bit more freedom, letting me see the patients, write them up, prescribe meds, and then discharge the patient. If I got stuck on my diagnostic plan, I would ask her about it. And she always had to sign off on the prescriptions, which is good, because I don't know a lot about meds yet…

The night was long. We had SEVERAL (more than half!) of our patients come in with abdominal pain. Which is usually a longer work-up. Which is ok, but it's hard when someone comes in complaining of the same belly pain for 6 months and then they pick tonight, at 3 am, to decide it's an emergency. Really?

I had a hard time staying enthusiastic about seeing patients because my preceptor was getting tired of it, so there was a lot of exhausted energy floating around. But we had really great nurses working with us (the pelvic room was ALWAYS set up fully and stocked for us) so we toughed through it.

We had a lady come in around 4 with a big wrist lac (short for laceration, which is just a fancy name for a big cut). I got excited about sewing it up, but after numbing her up and checking to see if her tendons were intact, I found out one was severed, which means we had to call the hand surgeon.

Which is ok with me, she had 5 kids with her in the room (all telling her to be brave, it was precious) and I wasn't looking forward to sewing her up because she was so scared.

Then we ran out of patients around 5 am….lame. But I got to get some extra sleep, which was MUCH needed!

……………….

Night 3 was lame. Basically, it was Saturday night and busy. I got to work with 2 NEW PAs when I got there which was cool, but I didn't really know who to report to or what to expect. I did get to sew up a leg on my own and then I&D an abscess on a screamer…

But around 1am they left and 2 doctors replaced them. The doctor I worked with before told me she was "too busy" to have me work with her, so she had me present to the other doctor. He was a great teacher, but he expected me to know more than I did, and he didn't want me to write up anyone. And he saw EVERY patient right after me and then got his own history. Kinda lame. I did get to splint someone, watch a girl get staples, and I&D another abscess though, which was neat!

…….

Night 4 was cool again. I worked with the same preceptor (a FNP-C) that I worked with the first two nights, so we started out with a level of trust. She knew what I knew, and I had a set of expectations to live up to.

I saw a REALLY sick girl with pneumonia. And then a sick boy with the same thing. They were both so small and sweet. I called the little boy "buddy." But he said, "My name's not Buddy.  They call me Fat Buddy." But he wasn't fat.  So I'm not sure why, but either way, it was adorable!

Then I saw some abdominal pain (everyone, it seems, has abdominal pain.)

I watched my preceptor glue a 4 year old back together, and he was precious. SO brave (he didn't cry once!) and so cute. I had to give him a high five on his way out (and we gave him an ER popsicle!)

Then I tried to glue a little 4 year old girl back together. Except her Grandmother thought she should have stitches (for a 1 cm cut…) So I educated the Grandma on why glue was a better option (less painful, less numbing for a kid, no needles, faster) so Grandma let me do it. And then the kid screamed when I cleaned up her finger (I used betadine, which doesn't even sting!) So Grandma yelled at me for not numbing her up. BUT WE NEVER NUMB people we glue. And so I educated Grandma about numbing. Whatever. The kid was fine in the end (she probably didn't even need glue because her cut was so small).

I saw a girl at 3 am with a 4 day history of "seal-like, barking cough." Those were the words right out of her mother's mouth (which rang bells in my head, like she read the notes I studied for pedi block!).  I'm not sure why it was an emergency she needed to come in at 3 am for, but we diagnosed her with croup, and sent her home with steroids.
My preceptor wanted me to staple an 11 year old, but since the 11 year old was a girl, she let me stitch her since the wound would heal prettier. My preceptor told her she was lucky to be a girl so she wouldn't have a scar. Really though, she was lucky a student was following my preceptor, because I don't know if my preceptor would have slowed down long enough to stitch. My preceptor told the girl that I would stitch her, and that she could give me an F if I didn't do a good job.

I had forgotten about that, but when I was finished, the girl told me I got an A+. Sweet!!

At the end of the night we saw a funny pregnant lady. I won't get into the story except to say that now every time we have a pregnant woman, they will get a pregnancy test BEFORE we do any other tests on them J

……………….

Overall, nights were cool. I did hit more traffic than I do for day shifts. I didn't see a lot of different stuff though. And now I realize that I'm becoming jaded.

I've been taught to always walk into a room on the patient's side. Which I still do, but now there are a lot more things that push me away from believing the patient.

I've learned what a true emergency is, and what isn't. And I've realized, that most of the ER stuff I see is really "Indigent primary care" instead of EMERGENT. Which is a learning lesson itself, really.

Each day has a theme: Eye Day to Abscess Day

My first day of rotations, don't I look cute/ terrified?

"it wasn't their swords that took the land
It wasn't their power that gave them victory

But it was your great power and strength
You were with them because you love them"
Ps 44:3


..........

Day 2: (eye day)

I started the day off getting my #2 #2… (2^nd DRE) Eeew. Then moved on to a male GU exam and a pelvic exam. Fun.

I got to play with a woods lamp.  And then do an eye exam on my own (after watching the Dr do one)

We were slow just after lunch so I played with a suture kit and sewed up some gause.  Then the afternoon raced by with a bunch of patients, some semi-acute things (heart attacks, strokes…) and some not-so acute things.

I diagnosed otitis externa, which I had never seen before.

Then I got home, realized I forgot about Tango class (I didn’t think about today being Wednesday.) Then my internet broke (again) and now I’m going to bed at 9 pm because I hate life. Basically.

...............

Day 3:

Pelvic Exam.  X 4

My first LAC!! Got to do 4 stitches (I was nice and let a 1^st year resident do a few…but I totally had to teach her how to use the instruments to tie because she used the “two hand tie technique,” which should really be called the “waste suture material and tie like a granny that sews technique,” It was neat to have that skill!

...............

Day 4:

LAC day!!

I got to put 12 stitches (2 internal) and 10 external in a lady with a huge lac on her leg. We did a few horizontal mattress sutures and some simple interrupted.  Then I did a digital block and stitched up a guy’s finger ALL by myself! No help.  And it looked good!

I also saw a MCL tear (diagnosed it by my self)

Saw a kid with (possibly) low platelets. Nosebleeds, petechiae, but ear pain and headaches.  I had to leave before the bloodwork came back. Which is the sad part of ER, we don't get to follow up on patients.

Then I did another pelvic exam, a lady with elevated liver enzymes (ast/ alt with 4 digits!) acute hepatitis, and saw some kidney stones. Oh, and an exploded lightbulb in a guy’s hand…

.................

Day 5 (week 2)

Monday was abscess day. EEEwww….an abscess is kinda like a big pimple. Except they can get HUGE. And just like pimples, they are really painful. Which is what brings people to the ER with them.

But before I had to deal with any abscesses, I got to watch a code blue, which is full out CPR with Defibrillation. Only it was the end of the code. They had tried everything, but the man's heart was failing. They did an Echocardiogram (Or ultrasound, the same machine they use to look at babies inside their mom's belly) to look at the heart and the doctor decided the heart wasn't going to make it. Then the heart lost all of its electrical activity. (imagine what it looks like on TV when the machine recording the heartbeat, an EKG, makes a flat line and a long continuous beep). That was just how it was.

I didn't know what to think.

I didn't know what to do. So I just stood there. A nurse ran down the series of events with me, explaining how codes usually run. Then they started to cover the body with a sheet and take out the tubes and I just watched. Then I walked away, unsure of what to think, how to react.

What are you supposed to do when you watch your first person die?

I wandered to the bathroom, then back to the part of the ER where my preceptor was located. She threw me a patient's chart and asked me to see them. So I did. And decided I would think more about the dead man and his family later.

A bit later that day one of the new PAs walked me through cutting open an abscess. Yuck. I really wasn't sure about it, but he talked me through step by step, so I felt good about it at the end. And later that day I got everything ready and did one by myself with him watching. I also got to sew up another finger laceration. I'm getting pretty good at those! Sweet stuff!

That night I had small group, and we went out for FroYo! Yum! I got to share with them about my day…abscess day…and talk about the code blue. It was good to share with girls and process the day's events.

…..

Tuesday I worked 11am-11pm. Except Tuesday didn't really have a theme. Maybe I'll call it coffee day because the PA I was working with walked to get coffee and I went with her. I had no idea there was a starbucks inside the hospital! So I got a caramel macchiato, yum!

I got to drain another abscess, sew up another big cut on a finger (except the man was in a lot of pain so I had to give him A LOT of lidocaine!), do another few pelvic exams, and see a bunch of patients.

Rotations: Day 1 Week 1!

I was in the ER all day today and didn't die! (Or kill anyone!!)


After dealing with our fire alarm at 11:45 pm (we wanted to die) my roommate and I got a few hours of sleep before saying goodbye the next morning around 5:30 am. I left for Charlton Methodist ER on the south side of Dallas.

I walked into the ER and waited to meet my preceptor while drinking coffee. It was quiet. I thought I would be a white cloud and it would be a slow day. When my preceptor walked in we had one patient. Not bad. I followed her in, watched her take a history, then listened carefully while she showed me how to enter patients into the EMR (electronic medical record) system.


Then she handed me a patient, "This one has a swollen lip, go see him."

Um….Ok….


"Hi, Sir, my name is Shannon and I'm a Physician Assistant student, tell me a little bit about why you're here today."


"Lo siento, senorita. No hablo Engles."


Shoot. My first real, honest to goodness patient, and I can't even speak to them in my own language. But somehow, we managed to communicate why he was there. I reported to my preceptor, only to find out HER patient only spoke Spanish too. Oh, wow. We were able to treat both patients, and by the time we were done we were FLOODED with patients.


So much for being a white cloud. Thankfully this wasn't my first time in the ER, even if it was my first rotation.


The rest of the day went by quickly. We saw a PRECIOUS little boy. He was having problems, but he smiled at me the second time I went in to see him, and let me listen to his lungs. Then he held the part of the stethoscope you put on the patient's chest (the diaphragm) up against his ear and laughed. He made my day J


We saw a total of 3 broken arms today. No other broken bones, just a lot of radiuses (radi ?) and ulnas. And a lot of crazy people that didn't really need to be in the ER at all. And a lot of really sick, get admitted to the hospital ASAP people.


And now it's 9:00 and I'm going to bed. Like a little kid. But I have to be up early again tomorrow…


The neat thing about working 7am-7pm is that I get to work before traffic, and leave before it too J

Medicine

Wednesday morning Kim (Justin’s Mom who is a nifty PA in Oklahoma) and I took 4 of the HCH kids down to 3 Corners to visit the hospital.  This hospital is more of a clinic with 2 doctors and a lab and 14 regular beds and a L&D unit where they deliver at least 15 babies each month.  We got to sit in with the doctor while he examined each of the kids.  

One rash of bacterial staph on a precious 8 year old that will take forever to get rid of because he lives at an orphanage.  2 periumbilical hernias that won’t get operated on because the holes are >3 cm and it’s considered a cosmetic surgery here.  And one case of possible pyelonephritis/ nephrolithiasis/ choledocolithiasis/ PUD.  The doctor relied on all the physical exam skills he could: percussion, kidney trapping, costovertebral angle tenderness…

Pure medicine :)

And now, to the soundtrack or rumbling thunder, we’re handing out toys, clothes, socks, and underwear.  The girls got bracelets and earings. The boys got bracelets and action figures.  

Never before have kids been so excited to get one action figure. Or one pair of socks.

Can I stay forever?!

Perfection

Yesterday we spent the day in Bamenda: at the market, checking out the language center, eating lunch with a missionary family, and getting ice cream!  How fun!  When we got back to HCH (2 hours later then planned) the children greeted us with screams and smiles!  They were so happy to see us and we realized we were SO happy to see them too!  We missed them all day while we were gone.

Which started a cascade of tears:

What happens when we leave in 3 days?

What if we don’t have time to finish mending the children’s clothing and school uniforms?  Will they have to run around in their unmended pants that they hang out of?

We’ve only done so much, but now we see SO much need, how can we meet it?

And probably most pressing: how do we learn to live in the United States in a culture that is so completely different after experiencing everything here??

Kadzi (don’t cry), Chimi (stop crying)

“Calm down

Deep breaths

And get yourself dressed instead

Of running around

And pulling all your threads and

Breaking yourself up.

If it’s a broken part, replace it

If it’s a broken arm, then brace it

If it’s a broken heart, then face it”

-Jason Mraz

The only thing we can do is soak up the time we have left here and do what we can with the resources we have in the time we have.  And we have to trust that God’s plan is perfect, even when ours is not.

Precious

Screaming Children.

They just got home for lunch and discovered surprises in their cubbies:  new mesh bags full of toiletries: 1 toothbrush, 1 “toothbrush protector,” 1 tube of toothpaste, 1 bar of savon (soap), and one sweet (candy).  

They screamed and jumped up and down for at least 3 minutes SO excited for the surprise!  I thought they were just super excited about new things that belonged to them (they have very little here that belongs to them).  But Justin told me they were really excited about the savon.  They’ve always used regular savon that you buy in bulk here: its the same savon they use to wash clothes and dishes.  

A big square of unscented soap.  But we gave each kid a small bar of soap that a bunch of my friends at school donated from the United States.  A plain, no frills, white bar of soap.  The kids have never ever been given scented soap before.  And “they’ve never felt like they were special enough for good soap.”

Heartbreaking.

Reflections of HCH

Who am I that my God could love me so much?

This morning, 5:00 am, we climbed the hill again.  This time, instead of 7 of us, there were 19.  We took a “shortcut” that required us to squeeze through several fences and up the side of a cliff and over a pass that was frightening.  But the whole way I had someone to hold my hand.  Usually it was Linda, a sweet 13 year old girl.  As we climbed, I realized how walking up the cliff holding her hand was like walking through life holding the sweet hand of my Lord and Savior, Jesus. 

When I was about to slip, she held me up. 

When I was frightened, she gave me courage. 

When I was exhausted, she gave me strength.

She fell a few times too, but I shared with her the analogy of how helping each other was like Jesus, and she smiled.  It was SO much easier to make it to the top with her help!

………………………………………………………………………….

Other sweet things so far:

Making it through the airport with no problems.

Getting to sit next to Justin on the bus ride to HCH and then being greeted by a bunch of adorable kids and staff!

Getting to talk with Bo-Jung (Emmanuel Ngala) about life: How frustrations are sometimes good because it makes you work through things, how I should stop stressing about everything being perfect (getting to do lists done, making sure the team is getting fed, checking up on things) and breathe.  Instead of stressing, I should relax and get it done, how precious the children are, etc.

Hearing the kids sing and dance with SO much enthusiasm at devotion.

Staying up all night talking with Kim because neither one of us could sleep.

Walking around the field talking to Charlotte or Justin or a sweet kid.

Getting my hair “plated” by a sweet girl.

Watching a movie surrounded by a million sweet kids and getting to hold my boyfriend’s hand.

Congo-line style offering at Church.

Holding Evet’s and Orelia’s hands…

Silly Girl

Amidst packing, studying, and planning something is bound to go wrong.

Of things that can go wrong, I guess this wasn't the biggest...

But honestly, who in their right mind throws away a bag full of pictures, meds, and a CD?  Apparently, no one but me.  It's a wonder I'm still breathing. 

I'm hoping that's all that goes wrong.

Pray for us as we fly out?!  We leave DFW at 1:20 pm!!

And I’ve got so much left to do…

A bit of encouragement from one of the sweet kids at HCH:

 
Hello my dear Shannon,

I'm very happy to write to you this letter. I hope you will also be happy to receive the letter. I want to thank you for coming to meet us here in HCH. I'm praying for you every day and I hope you're well. Always smile. God loves you. Thank you for coming to spend your time with us. Remember to always :-)

I love you Shannon,

Honorine

 

 

Honorine
DOB: 10/15/1998


 




"Let me reintroduce myself
As a man with a cause
I've had a lot of time to think
And look at who we are
And I've got nothing left to say
But we've got to carry on
And I've got so much left to do
But I'll start with this song

Why do they lie?
Why can't you see?
Get up everybody
Stand up with me

Let's Go! Everybody!
Let's Go! Tell 'em we're coming
Let's Go! Everybody!
Let's Go! Stand up with me!
Let's Go!
Take the world with me"

"Let's Go" by Cartel


 

 
Left on my to do list: grocery shopping, pick up last minute things (stuff for the team, things for the kids), go to school, study for a pharm final, learn something about Rheumatology, study for the Rheum block test, coordinate pick-up and drop off of supplies, have a fun weekend with my parents, pack, lead a few conference calls, send half a million emails, thank a million people who have been so great and so SO so sweet to me and the kids, etc…


 
But today in church we learned about the word ALWAYS. God is ALWAYS with us. He is with me now as I have a semi-melt down and tell Him over and over how I CAN'T do this and how I am incapable of doing anything. But he just smiles and tells me that's why He is in control and promises to be there for me.


 
Deep Breaths…


 
I'm so close now I can almost smell Africa!!

God made Kidneys too…

Unfortunately God made kidneys, which are an extracomplicated piece of anatomy designed to rid our bodies of waste…

So maybe it's a fortunate thing God made kidneys, and only unfortunate that He made them extracomplicated.


I thought about having a brilliant post comparing kidneys to God and how he is extracomplicated and rids US of the nasty things in our lives, but then that seamed cheesy and too deep to think about when I'm trying to learn the ins and outs of the kidney.

Hmmmm….

Sometimes I think I have a lot of the symptoms of Uremia (fatigue, restless legs, lack of concentration, irritability) but I'm pretty sure without the majority of the symptoms my kidneys are functioning just fine…

Other times I think I'm hypokalemic, because it just sounds fancy and sometimes I fit the profile (but not most of the time, thankfully)

And then I have a strong suspicion I'm going to get kidney stones because I don't drink enough water or eat enough citrus fruits most of the year and I do take calcium supplements, eat things with oxalate in them (chocolate, tea, spinach), and eat a lot of salt. Good thing I don't eat much animal protein because just knowing that I meet most of the requirements for renal stones is enough to freak me out…


I need to stop thinking so hard…

Good thing I'm trusting God to take care of the details in my life!

Somehow, breathe a little deeper now…

"Patience, child it will find you
Your deepest dreams will guide you
the moment that you're born
all night the fear inside will come through
haunting right behind you
don't let it get that far

Somehow, breathe a little deeper now
this is who we are
when we look into their eyes
don't fly so high
so high little bird
you'll get your wings clipped
we'll pick it up, pick it up now you've learned

Searching the moment that defines you
your deepest dreams remind you
get out before you're gone
now that all you hear is what surrounds you
push it out, get it out from around you
never stop and you will find it all

Somehow, breathe a little deeper now
this is who we are
when we look into their eyes
don't fly so high
so high little bird
you'll get your wings clipped
pick it up, pick it up now you've learned

We decided
We decided
We decided this now
So find out how we can survive
How we can survive
If we learn how to live our lives
If we learn how to live

Somehow, breathe a little deeper now
this is who we are
when we look into their eyes
don't fly so high
so high little bird
you'll get your wings clipped
pick it up, pick it up now you've learned"

Cartel "This Is Who We Are"

 





 








Deep Breaths. School will get done. Plans for Africa will get finished. Support will come in.


God has this under control:



1 Peter 5:7
"Cast all your anxiety on him because he cares for you."



I'm pretty sure all covers tests over kidneys. Not that I don't have to work hard, just that I don't need to WORRY about working hard. I shouldn't worry about anything. I just need to breathe. I need to TRUST GOD to help me survive.



2 Chron 20:17, 27

"You won't need to fight in this battle. Just stand strong in your places and you will see the LORD save you…

Then Jehosaphat led all the men from Judah and Jerusalem back to Jerusalem. The LORD had made them happy because their enemies were defeated." (from my quiet time a few days ago)



Have courage, sweet girl. God will be there. He'll save the day, trust Him. And don't forget to breathe…


 

Only...

PA School + Planning a trip to Cameroon + Breathing + the million other things I do = Impossible

PA School + Planning a trip to Cameroon + Breathing + the million other things I do + God = Possible in HIS strength...

Got it!

Thanks for all of you who are supporting us!!  More to come shortly...

Meet Charlotte

Charlotte is my friend.
 
She's pretty amazing and exciting. She loves adventures and cupcakes and kids. We just set up a tent in her living room because she's that cool.



But the coolest thing about Charlotte is that she loves Jesus, and listens to Him. Charlotte is coming with me to Cameroon to love the kids, share God's love tangibly with them, and experience all the wild things God has in store for us.
 
Charlotte will be guest blogging on my site, so look forward to it! I'll let her tell you more about who she is and what she does :)

Ocean Eyes

"Painted skies.

I've seen so many that cannot compare,
To your ocean eyes.
The pictures you took
That cover your room,
And it was just like the sun
But more like the moon.
A light that can reach it all.
So now I'm branded for taking the fall."

Mae "The Sun and The Moon"

I'm getting ready for my trip to HCH this year which means a few things:

I'm stocking up on protein bars and shakes,

I'm praying hard for the kiddos over there,

And I'm sending letters and emails like crazy trying to lead a team and raise support.

Sometimes it's exhausting trying to study for school and get ready for an emotionally intensive trip to a foreign country. But one look at the precious, ocean eyes from last year's trip is enough to remind me that it is worth it. That God calls us to care for orphans. That He loves us just like He wants us to love them. Does God really look into my eyes and see precious, ocean eyes?

Wow.

I know He'll show us amazing things this year. I know He'll move in awesome ways. Because our God is huge and wonderful and beautiful :)

Harvest Children's Home, Cameroon, Africa, May 5-16, 2010

Family and Friends,

Last year, I fell deeper in love with God and some of his amazing children at Harvest Children’s Home (HCH), an orphanage in Cameroon which is supported by an organization from the United States called Cry Cameroon. I got to experience a different culture, love some precious children, and bring them God’s hope and joy.

This year, God is calling me back. My primary goal is to do a yearly health care checkup on the kids, but I also want to fix up some of their school uniforms by teaching some of them how to sew, lead nightly devotions, and disciple some of the older girls.

Please follow my blog! I’ll be updating it periodically before I leave and while I’m there with specific prayer needs and information on what’s happening. I’ll also post fun pictures!

I’m in need of your prayers! I’m leading a trip this year, full of people who’ve never been to Africa before. I’ll need prayers that God reminds me daily to pray for my team and that He prepares us to do His work, not our own.

I’ll be taking as much as I can with me for the kids and the HCH staff. They are in need of medicine, children’s clothes/shoes, soap, toothpaste, towels, blankets, body lotion, vitamins, etc. If you have any of these things that you’re willing to donate, please let me know because I’d love to pick them up from your house! (or send you money for shipping)

If you are able, financial support would be very helpful! The trip is going to cost around $2,000 to cover travel, food, and new materials for children’s clothing. Thankfully, I already have all of the medical equipment I’ll need to do physical exams on the kids. If you would like to donate online, please click here. Please be sure to fill in the box "Please designate my donation to this project:" with my name, "Shannon Helster's trip."

If you are interested in donating but would not like to do so online, you may make a donation directly to Cry Cameroon Ministries by sending a check or money order to:

Cry Cameroon Ministries

6620 Finecrest Drive

Colorado Springs, CO 80923

Please be sure to write the check to "Cry Cameroon Ministries" and include a memo of: "Shannon Helster's Trip" so that I can get you a tax receipt as soon as possible.

For more information about how you can pray/care for/ support/meet the kids at HCH, please ask me or visit www.harvestchildrenshomes.org

Thank you for your prayers and help!

With His love,

Shannon

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