Failing

After my end of rotation exams on the 27th, I was so glad to have a weekend free of rotation thoughts and it was so good to unwind. Unfortunately, my relaxation ended when I got the exam results back for the two exams I took. For the non-elective rotations, the preceptor evaluation makes up 60% of the rotation grade, the end of rotation exam makes up 30% and 10% is for completing some tasks and attending callback day. To pass the rotation you must score 75% or higher. My score for the emergency medicine exam came back listed under “raw score” but it seemed more like a percentage from the report sheet so when I calculated my score for the rotation it showed I just passed by a matter of points. After I thought about the report, I started wondering if the raw score was a percentage or if it was a true raw score of the number of questions I answered correctly. Since the test was out of 120 questions, the percentage would be even lower and that would mean failing the rotation. Failing the rotation is bad enough but if I failed a rotation I would also be graduating a few months late because I would have to repeat the rotation.

Once I had this possibility in my mind, I got very nervous within. To me, failing school is a true failure in life. I know this has been a very big obstacle for me especially in the past didactic year and it weighs on me a lot. I become so occupied with not failing because I am so scared it will happen. In the past year, this has been something that I’ve struggled with because the majority of me wants to hand over the control to the Lord but then there’s a small sliver of me that can’t let go of all the accusatory thoughts. Thoughts such as “you don’t deserve to pass,” “everyone is smarter than you,” “you don’t try hard enough,” etc. Even sharing these posts was a big step for me because I feared that people would witness my inability and would maybe see me failing a rotation or not being able to complete PA school. One of the hardest things I had to experience was the fact that no one outside of my classmates knew what I was going through in school, so this was something I had to carry by myself. For the most part I tried not to let this stress show through because I didn’t think it would benefit anyone and I really did pray and commit these thoughts to the Lord every day.

These thoughts come up more strongly some days more than others, but thank the Lord He is my protector and my sustenance. He is capable of protecting my thoughts and providing strength to continue.

It still isn’t confirmed that I passed the rotation, but I am at complete peace. While I was thinking about the possibility of having failed the rotation and needing to be held back a bit, I kept thinking why this would happen. I asked the Lord about it and I didn’t get a clear answer but I was led to pray that His overcoming life would bring me out of my sadness and bring me to know Him more. I think that was more precious than had I just been thankful for completing one rotation.

On most days I wish PA school could be smooth sailing but I know this season of my life has become much more meaningful because through it all I’ve seen how faithful my Lord is and how much He knows me and cares for me.

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The End of a Beginning

So today was the last day of my first rotation. Reaching this small milestone also meant leaving my new friends, which was my least favorite part of today. I really couldn’t have asked for a better rotation to start the year. I had the best preceptor, the staff was great, and I got to see and do so much. In the beginning I was terrified of having emergency medicine as my first rotation, and now it’s hard to leave.

My preceptor was fantastic. From the very first day he was the most approachable guy, the most patient and encouraging teacher, and a great practitioner to his patients. When we reflected on all the procedures we did the past few weeks, he rattled off everything we did, almost more proud of my progress than I was. It really is such a blessing to a student when the preceptor is a teacher, a cheerleader, and an experienced clinician all in one. Not only did we have a great time seeing patients, but we also had a great time during the lull between patients.

In addition to my preceptor, the other PAs and doctors were all welcoming and kind to us students and even took time to teach, share cases, and answer questions when the opportunity arose. It was helpful to observe the way they practiced, and it definitely did not hurt to have extra instruction and professional opinions. I interacted less with the nurses, but they were all nice for the most part and taught us how to do venipunctures/IVs, so I’m indebted to them. There were also many other staff members who were key in helping us interact with patients and have the best experience possible. I have a feeling this might not be the case at many other sites, so I don’t take it for granted.

With regards to the specialty of emergency medicine, it has its pros and cons. Emergency medicine is a specialty that is fast-paced and deals with the present situation. I think it’s a good match for people who enjoy medicine and don’t seek out building lasting relationships with patients. There is quite a bit of hands-on work that goes on, which I find enjoyable. As for turnoffs or drawbacks, the emergency department is a smelly, dirty, noisy place. Sometimes the patients are difficult, possibly uncooperative or belligerent. Since we often do not know the patient’s medical history, it is sometimes challenging to treat without knowing the whole story. Most days are long and intense, but the thrill of not knowing what is coming next and being able to get down and dirty while practicing medicine is enough to keep many going.

All in all, I will miss the never-ending action and the many laughs with the staff that went on at this rotation site. Would I consider becoming an emergency medicine PA? Perhaps. It’s too early to say. But this rotation will hold a special place in my heart, and the following rotations will be hard to beat.

Rest and Renewal

I am so tired. I feel like ever since PA school started it’s just been a constant push to keep going with no downtime. Even during the two weeks of break I had between my competency exam and the beginning of rotations in June, I traveled to Minnesota for a church retreat and flew back to New York only to fly out again to California for a wedding and return the night before rotations started.

The past four weeks of my first rotation have been great overall, no doubt about it. Despite the relatively good hours, especially compared to some of my classmates, I feel like I really don’t have that much time to just breathe. I can’t even pinpoint why I feel so tired. Maybe it’s because I’m on my feet the entire time I’m working, or maybe it’s because I’m always frantically trying to search my brain for differential diagnoses and their treatments. Perhaps it’s because I don’t really talk to or hang out with people when I’m not working and I’m jealous of everyone on social media enjoying their summers. Or possibly because at the back of my mind there’s a constant reminder that I need to study for my end of rotation exams, I need to work on my assignments for school, I need to write for my rotations journal, etc. I’m thinking is a combination of everything.

I know I mentioned feeling isolated before, but it is quite a strange experience, feeling isolation during PA school. For example, right now my family is out roadtripping and the rest of my extended family is heading out tomorrow to join them while I stay back because of rotations. Usually in the summers my friends and I grab every moment we can to hang out and soak in as much sun as possible (well, those of us that want to get more tan), but this summer I’m not able to do that. My parents keep telling me that rotations is only for one year and afterwards I can do whatever I want. But after rotations come boards (more studying, great) and after boards come job hunting and adulting.

I suppose this is a good time for me to turn on some worship music and praise my Lord because even when my soul feels heavyespecially when my soul feels heavyHe is worthy of praise. He is the only one who understands and can say “I know,” and really mean it. When I sleep tonight I want my heart to be praising Jesus and when I wake up I will praise Him because He has given me a new day full of His goodness and mercy and help to continue onward.

The Art of H&Ps

In medicine everything is evidence-based, and labs and imaging and presenting symptoms are used evaluate patients’ physical state. When patients come in with a complaint, that’s what we start investigating. We look for pertinent positives and pertinent negatives and see if we can ask questions and perform physical exam tests to rule in and rule out disease processes to come to a diagnosis or differential diagnoses. It sounds straightforward enough on paper, but when I’m thrown into a situation in front of a patient, it seems as if all streamlined reasoning goes out the window.

This way of coming to a conclusion allows for sound diagnoses, but at this point in my clinical practice (meaning all of three weeks), I am still very much a novice at the art. In the classroom we learned to start off questions with the OPQRST mnemonic: Onset, Provocation/Palliation, Quality of the pain, Region/Radiation, Severity of the pain, and Time. When I first meet the patient I ask what happened or when did the pain start, and after that I try to ask the PQRST questions but sometimes I feel like I am winding around the questioning path before I feel like I’ve gathered an adequate amount of information.

This leads to some awkward oral presentations to my preceptor because I present with my partner and we start off with the presenting symptoms but sometimes jump around the normal presentation order because of the way we asked the questions. Thankfully, he is very gracious and mostly cares about what’s going on with the patient and overlooks our wacky history.

Another key to getting a good picture of what is up with the patient is avoiding making assumptions. Though it is not done out of ill intentions, even if it is done out of honest naivete, the history that the patient presents is tarnished. A few days ago, there was an elderly patient who came in with the chief complaint of vaginal bleeding. Immediately my brain went to a cancer of the female reproductive system. We continued with the history, how did it happen, has this happened before, is there pain anywhere, etc. It also so happened that the patient was not happy she was there and her son was trying to answer all the questions for her. Having family members around can be helpful, but it also makes it harder to know the real story. Anyways, we took the history and presented to our preceptor, and he reported to the attending and his response was, “How do you know it’s vaginal? It could be urinary or rectal.” I didn’t even think of the possibility that the chief complaint might not be the actual problem, though I did ask about the patient’s urination and defecation history. Turns out after a pelvic and rectal exam and after the patient urinated, the bleeding was actually coming from the urinary tract. From there the case became GU cancer until proven otherwise.

Even this early in the game of my clinical practice, my mind sometimes jumps to conclusions, which is something I’m working on avoiding. A patient came in with very nonspecific symptoms including a sore throat, cough, vomiting for a few days and was also giving me (and later, my preceptor) a lot of attitude because she had been waiting to be seen for a couple hours and felt very sick. From observation and speaking with the patient, my mind already made up in my mind the patient had a minor viral infection. My preceptor did a quick exam and waited for the labs to come back, but we both were thinking the same diagnosis. When the lab results returned, the WBC count was a little high, which made me stop because that made it seem more serious than I thought. But after a repeat exam, the diagnosis of a viral infection remained and the patient was sent home.

Both these instances made me stop in my tracks and reevaluate what I had been doing by failing to thoroughly investigate details and forming opinions in my head before seeing the whole picture. Of course, having differential diagnoses in mind help guide the history and physical, but it is also important to cover all the bases before coming to a conclusion. Needless to say, I have much to learn and a ways to go to become a fully competent PA.

The Epidemic is Real

After telling people I’m currently working in the ER, the question, “What’s the craziest thing you’ve seen so far?” has come up quite often. In the past two weeks I have seen a lot of cool stuff and a lot of boring stuff, too (no offense to the patients). I suppose I was least prepared to witness patients who come in from abusing illicit drugs, such as heroin, and are often on more than one drug. The opioid epidemic is quite apparent in New York City, as well as throughout the rest of the country. According to a report published by the CDC, between 1999 and 2014, the number of opioid overdoses has almost tripled in the United States. Of the 47,055 drug overdose deaths that occurred in 2014, 61% involved an opioid (1). A report from the New York State Department of Health estimated a crude rate of 6.1% of outpatient emergency department visits were due to an opioid overdose and a crude rate of 3.2% of hospitalizations were due to an opioid overdose (2).

I have not personally interacted with these patients when they have come to the emergency department but I have observed them. The first time I witnessed a patient on heroin, the patient was aggressive and not at all cooperative. He kept yelling at everyone, especially at his mother, cursing at everyone who tried to talk to him and touch him. It was quite interesting to watch the doctor and nurses work amidst the chaos and aggravation. I remember the nurse assigned to the patient’s bed had an extremely frustrated look on his face because he was nearly wrestling the patient to give him sedation medication. Once the patient was sedated he slept for a few hours and when he woke, the same happened again, only the following times it took even more medication to sedate him. It was hard to watch this patient, who was a healthy young guy, succumb to some white powder.

The National Institute on Drug Abuse lists drowsiness, mental confusion, nausea, constipation, respiratory depression, and euphoria as the effects of opioid abuse. Additionally, “restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and involuntary leg movements” are withdrawal symptoms that may occur with opioid dependence and addiction (3). Though these are the effects listed on paper, I feel they are far more detrimental. The patient’s family was distraught with worry and fear because their son/brother turned into a monster of sorts under the drugs and he had threatened to kill them at home. So even though the patient was experiencing the effects of drugs in his body, everyone around him was being affected to varying degrees, some more than others.

Another patient who came in on heroin was extremely physical and it was a little frightening to witness. He had handcuffs on his wrists and was restrained to the hospital bed but even then, I felt like if became even more enraged he could have turned into the Hulk right then and there. Because he was thrashing and yelling so violently, three built men (two security guards and one policeman) had to hold him down while he was given sedation medication.

When working with patients, you have no idea what you will see next. These two patients were most definitely difficult to manage and their cases were anything but predictable. Indeed, these two scenarios were like nothing I had ever seen before, but I would prefer that these encounters not just end as a riveting story. They beckon increased awareness about the opioid epidemic that is occurring right now, an epidemic that stems from addiction that can start from a regular or longer-term prescription. Not only awareness is needed, but also education for prescribers of opioids, people prescribed opioids, people abusing opioids, and support systems to know what to look for, where to look, and where to turn to for assistance. My heart hurts when I see patients in a state where their bodytheir liveshave fallen to such a dangerous addiction. Prior to rotations I had heard and read about the opioid epidemic, but seeing it in person is something else.


References

  1. Rudd RA, Seth P, David F. Morbidity and Mortality Weekly Report (MMWR). Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm?s_cid=mm655051e1_w. Published December 29, 2016. Accessed July 8, 2017.
  2. New York State – County Opioid Quarterly Report. https://www.health.ny.gov/statistics/opioid/data/pdf/nys_apr17.pdf. Published April 2017. Accessed July 8, 2017.
  3. Which classes of prescription drugs are commonly misused? NIDA. https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/which-classes-prescription-drugs-are-commonly-misused. Accessed July 8, 2017.

 

It’s Offitchal

I can’t believe it. Well, I guess I can because I’m physically at the hospital seeing patients. But still, what? On Monday I started my emergency medicine rotation. Prior to starting I went to their Human Resources department and got clearance and corresponded via email with my preceptor. I figured on my first day there would be some sort of orientation program to get acquainted with the hospital, the emergency department (ED), hospital procedures, etc. Instead, my preceptor gave another student and me a quick tour (as in: here are the exam rooms 1-16, here is the supply room, here is the staff bathroom) and soon after we were sent to see our first patient.

Since my classmate and I both have the same preceptor, we see all of our patients together and usually switch off when doing procedures. When I took patients’ histories on Monday, I really didn’t know where to begin. How do I even ask what’s wrong with the patient? How do I ask a follow-up question to arrive at a conclusion? Remember to ask about past medical history, surgeries, medications. Do I ask about social history? Family history? What did I forget?? After we gathered all the information we deemed adequate, we would report back to our preceptor. Usually our preceptor would ask what was up with the patient and most of the time he would ask us a question about some aspect we didn’t think to ask the patient. Then our preceptor would accompany us back see to the patient and he would bang out an entire H&P in short amount of time. I’m still in awe of his ability to make the patient feel comfortable and also get to the bottom of the chief complaint and perform an exam in a swift and efficient manner. At the same time, I feel so inadequate at interviewing patients and knowing what exams to do for a focused physical.

In school all the procedures we practiced were done on models and plastic or rubber models are not exactly the same as humans. So far I have done, to name a few, a foley catheter insertion on a male patient, female pelvic exams, ultrasounds, male rectal exams, wound care, fracture splints, sutures for a laceration, suture removal, and venipunctures and IV placements. In my opinion, venipunctures and IV placements have been the most challenging because my skill has not been honed combined with the fact that not everyone in the ER has easy veins. My preceptor is really open to letting us see as many patients and do as much as we want which has been a great help in adjusting to and becoming familiar with PA life. It’s been a learning curve, but I love the rotation so far.

At my ED, there are two attendings and two PAs during the shift between 12 p.m. – 7 p.m. All the doctors and PAs I’ve met so far are all really great to work with and are very knowledgeable, skilled, and calm. These three characteristics are imperative to effectively treat the wide range of ER patients. Some come in with a minor scratch or come in due to trauma. Others come in with infectious diseases. Others come in because they were found on the streets or are intoxicated. Others come in from other facilities and you’re not really sure why they’re here. Some cases are very straightforward and have very cut-in-cloth plans. Others present with very nonspecific symptoms and workups may or may not help with diagnosing. Sometimes cases are very critical and complicated to stabilize and/or treat. On my second day a patient coded and it was so different than what I imagined. In my EMed and ACLS classes I pictured codes as a big event with controlled commotion but in actuality it was a fairly mild scene with the attending giving orders, a nurse giving CPR, and other nurses helping with medication administration. I found it funny that since the patient had already been admitted, a different team was supposed to be responsible, but they didn’t make it quick enough. By the time the whole crowd of attendings and residents made their way to the ER, the patient had been brought back and stabilized.

Another obstacle that is very apparent in New York City is the language barrier between many patients and the practitioner. I would say my Mandarin is conversational, meaning in a clinical setting I can ask patients all the normal questions about their presenting symptoms and history but certain terms such as specific body organs or specific medications I’m not very good with. So far I’ve helped interpret and have also conducted several H&Ps in Mandarin, which I never thought I would be doing when I was growing up in suburban Minnesota.

Every morning when I walk from my car to the emergency department nerves wrack my stomach, but I am completely embracing this rotation. It’s a challenge medically and mentally and also physically (I get hungry during my shift and my body gets tired from standing) and yet I am so grateful for the awesome experience I have had thus far.

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