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