February in Pictures

Scrubs met Frosty the Snowman!

Scrubs and Shannon's Shadows

Driving out to Sulphur Springs!

Day 1 of my Pedi rotation!

The pretty flowers my preceptors had in my room :)

I love these people: Mr. Brent, Mrs. Nicole, and Dr. Sherri :) Celebrating Nicole's 1st paycheck!!

Ob/Gyn Reflections

This is the essay I wrote for school with a few extra things thrown in (because I didn’t want to brag about how good the PAs looked in my school essay, and I didn’t want to go into as much detail for school).  J

This was a great rotation.  It was the first time I thought “wow, I could really see myself doing this one day and LOVING it!”

I learned so much and had a lot of fun! I enjoyed several things about Gynecology: the pace of working in an office, getting time to educate your patients, seeing gynecology surgeries, and following patients for more than one office visit.  I had fun on gynecology learning and getting to see so much.  I didn’t get to do a lot, but I feel like my doctor made up for it with the way he let me see so much from surgeries to office procedures.  I really enjoyed Obstetrics.  Working with women to help them deliver a baby was such a special moment to spend with them.  And seeing a new life be born, knowing that I facilitated the birth, was really amazing.

My last day on obstetrics I got to deliver 3 babies all on my own (with someone standing right behind me just in case), plus watch a set of twins be born.  The first baby was breech, so I got to see how to deliver a breech baby, which was something I had been reading about outside of the objectives.  I was SO excited about getting to see twins, since my R3 (who had been at parkland 3 years as a resident) had never gotten to see twins be born!!)   I finally perfected my one handed knot tying, which I strongly recommend we learn in our Clinical Skills class, because it’s always fun when the PAs look good in front of the medical students by helping them learn too.  Several of the PAs were the first to learn how to tie a one handed knot and were helping the instructors teach the med students. 

I was really thankful for my team of residents and attending on obstetrics.  My R4 sat down with us about once a week and went over a topic from etiology to treatment, asking us what we knew and helping us remember the treatments.  She was always giving us facts about treatment and then asking us to recall it later, which is one of the ways I remember things the best.   Our attending doctor also sat down with us and talked through topics, he had great slides that helped us learn more than just what we read in our books.  Everyone else on the team, especially the R1, were great at teaching hands on when it came to delivering babies, suturing, or tying knots.  I know I learned a lot on obstetrics, with all of the hands on learning and verbal learning!

I feel like I met most of my goals.  I learned the etiologies and treatments for gynecologic problems in both parts of the rotation.  I learned to interpret labs and be proactive about women’s health.  I felt like I learned a whole new set of suturing skills, and I was able to help the medical students on my team learn them too, because I was the first one to perfect the skill.  This was one of the first rotations I felt like I knew possibly more than the med students I was working with (because we had the ob/gyn block in the summer, and they were hearing things for the first time) which helped me when we would go over things as a group and I felt like I was teaching them things.  I liked going to the med students and asking them a question about what I didn’t understand, usually they would have no idea so we would look it up together.  At the end of the rotation one of the med students brought in a practice test and so we worked through it as a team of students.  Several times I was the one explaining why the answer was right, instead of the other way around.  I usually feel as if I’m on the same knowledge level with the med students, but I really loved knowing a bit more. (and now I’m done bragging)

This was also the first rotation I got to see a PA working.  I’ve seen many PAs before school started, but this was one of the first times I got to be in the room with a PA analyzing how what she did was did and the doctor did were essentially the same.  It gave me more confidence knowing that I was getting a great education and I would be able to help people like that one day. (especially since she was educated at UT Southwestern!)

Catching Babies!!

I’m on Ob right now, which basically boils down to me catching babies!!

I wish I had a cool picture to post with this blog, but I don’t, so maybe I’ll do a picture posting blog later about all the fun stuff I do with my free time.  I have a relatively large amount of free time even though I work about 50ish hours a week: I work two 12 hour days and then two 5 hour days, for 6 days each week.  But we start work around 5 am each day, meaning I’m done by 10 am on my 5 hour days, making it feel like a day off! I tend to go to bed around 9 every night though…

Thursday I caught my first baby.  I had done c-sections before (assisted in them) and delivered a placenta, but I had never gotten to help with a vaginal delivery. 

I was on L&D West, which is where they send all the “high risk” pregnancies (women with diabetes, high blood pressure, etc).  I was on c-section duty that day, but two babies were ready to be delivered at one time, so the resident I was working with got shifted from c-sections to immediate birth, and I followed!  It was just me and the resident and a nurse in the room.  The mom was ready to deliver (we could see the baby’s head!) and we had her give three big “pushes” coinciding with her contractions, then she would have gotten a rest period, but on her 3^rd push, the baby came out! 

Traditionally, the baby’s face delivers first, then it turns outward and its first shoulder gets delivered, then the rest of the baby slides out.  We got the baby out together, then I suctioned out the yuck from his nose and mouth, then clamped the umbilical cord, and handed him to the nurse.  We started to clean up the mom, and the dad was with the nurse taking pictures of the precious new baby boy. 

But the mom wouldn’t stop bleeding. 

We went through about 10 towels of blood as my resident looked for a cut on the inside of the mother.

She finally found one on the cervix, which traditionally bleeds a lot! She called in an upper level resident to fix it (she was a first year resident, so she called in the 4^th year)  Who was followed by two attendings.

As they worked to repair the cut (which wasn’t deep, just far inside) the mom kept bleeding.  

A lot.

So they turned the delivery room into a full out operating room (the L&D west rooms are set up like operating rooms in case something bad happens, but this was supposed to be a low-risk delivery, nothing bad was supposed to happen!)

I turned into a makeshift scrub nurse (the person responsible for handing the doctors instruments when they call for them: imagine like it is on TV when the doctor calls for a scalpel and then someone hands it to them, but that someone was me!) 

Only they called for “suction” and towels and instruments with funny names that I didn’t know and then for needles….

So they sewed up the cervix but the mom KEPT bleeding.

Turns out she had uterine atony, which is basically when the uterus (which is full of blood vessels that just kept the baby alive) doesn’t clamp down like it should so all the vessels keep bleeding. (you can read about it here: http://en.wikipedia.org/wiki/Uterine_atony )

But thankfully, it was only the lower 1/3 of the uterus and we had anesthesia doctors to help keep the mom sedated.

And finally, after 3 hours and 3 liters of blood, we finally got her to stop bleeding.

Thankfully.

So my first baby was delivered and thankfully both mom and baby are doing great! I had a lot of fun delivering the baby, watching a new life be born right before my eyes! It was really neat to share such a personal experience with the family, they were so excited and so happy to have a new baby!

Not everything on L&D is so fun or so rewarding (some things are downright hard, like when a woman younger than me (and I’m 23) who has been pregnant 8 times says she doesn’t want birth control because she thinks an IUD gave her cousin cervical cancer…which is impossible, cervical cancer is an STD) it’s heartbreaking seeing the cycle of misunderstanding and un-education continue.

I’d love to one day explain to women how their bodies work, help them become more educated so the cycles of poverty stop with them. 

Maybe one day…

Ob/Gyn

 Last day of Gyn Surgery!

Day 1 Of Gyn Clinic!


My first 3 weeks of Ob/Gyn was spent in a Gynecology clinic. I honestly think I learned more about the female body on this rotation than I did in my anatomy class. Especially about Kegel muscles. Ladies, if I can stress one thing, it's keep your kegel muscles strong! They're important for 3 things (that I will go into detail on if you and I have a one-on-one conversation, because I don't think the blogging world wants to hear about pee, poop, and sex.)

I got to sit in on surgeries: hysterectomies, pelvic wall repairs, and even a laparoscopy! It was neat to get to see more surgeries and be reminded of anatomy!

I really enjoyed being in a clinic. Starting at 8 am (even though the clinic was half way across town) was wonderful! We got an hour for lunch and we were done (most days) by 5! We really had time to sit down and get to talk with our patients. I loved how my doctor would help them with all kinds of things, not just gynecology.

And women, if you had a vaginal birth and now are experiencing symptoms of low back and/or leg pain, urinary leaking when you cough, sneeze, jump, lift, or laugh, having problems with defecation, or sex, then my doctor can fix you and put you back to the way you were before you had your first baby. And if it's just constipation, he'll recommend "Nopalina." You can only buy it at a Fiesta or a Carnival, but it's cheap fiber that's loaded with good stuff. He also recommends a wide variety of other products, some getter than others…

The most interesting thing I learned was about Ibuprofen. It makes your menses shorter and you lose less blood. Don't ask me how it works though, because I don't know, but I'm sure if you do a quick google search, Dr. Google would give you some info.

But now I'm on Ob at Parkland, getting to hang out with new mommies of precious babies. More detail on that later in the rotation!

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…