Clinical Rotations

Midway Ecuador Update

2010-07-19T12:54:00.000-07:00

Must at least muster the energy to put up a mid-rotation post. My mini-list of excuses: A constant bug draining my health, limited connectivity, even more limited time, and giant lunch after clinic + sweltering heat = nap time.

Church in Cuenca

Anyway, I’m here. Long story short: I eat papayas and croissants for breakfast. Every day we meet for gas-station coffee, which is actually the best coffee in town. We take 2 bus trips, equaling about 45 minutes to get to the clinic every day starting in our neighborhood which is pretty upscale, with its shopping plazas, fountains, palm trees, and “hired help”. Through the morning, we migrate inward, to the depths of the chaotic, dirty, loud, humid city. We stop in an unknown neighborhood, on a wet, muddy, garbage filled street. The first day we were told to “definitely not keep going down that hill”. We heed the advice every day, and assure ourselves that nobody will harm the Blue Gringo Smurfs, all cheerily walking down the middle of the street in our blue scrubs.

Fruit Stand in Cuenca

Stepping over the occasional lounging stray dog in the waiting room, we make our way every morning to our patient exam room. Here people essentially come and go all day. We stay put. People burst in during the middle of patient histories and waltz in and out during exams. We are in the beehive and the buzzing is near incomprehensible Spanish. We try to keep up with the fast pace and the maddening crowd and the strange Western-Medicine-Reflexology-Antibiotics-For-All-Slash-Don’t-Really-Examine-The-Patient type medicine that is being practiced here. Healthy, healthy kids walk out with a stack of 5 or 6 prescriptions. In the end though, the doctor is an amazing person, a staple of this community, and is bringing a great service to people in great need.

It feels good to help at this clinic, but the experience is cheapened a bit, when we return by bus to the Great Suburbs of Guayaquil and see how the Other Half lives. This is where they want us to stay, to sleep, and to eat. They want us to enjoy all that the religion of Consumerism has to offer in its great Temple (The Mall). It feels a bit like a volunteer vacation, where you snorkel for 6 days, build a house on the 7th day and go home and brag to all your friends about how you are such a worldly, compassionate philanthropist. I’m not buying it. The people that live here need to put down their Gucci and step up and take care of their own. Perhaps we should live amongst the people we are treating every day and not be blinded by fancy shiny things on the other side of the bridge every afternoon.

Oh, am I ranting? Oops. Actually everything is fine. And with all that is said above, I actually LOVE my host family. Mariana is an amazing person, a wonderful cook, a self-less mother to her own son and her (temporary) Ohioan son. I have been welcomed here like nowhere else and I will miss this home the moment I leave.

Montañitas Hangover Cure

Continuing on with the day, after the aforementioned giant mid-day meal (almuerzo), I sluggishly make my way to Spanish class from 5:30 to 7:30 every day. Homework, readings, exams, and all! Our teacher takes this class very seriously and we struggle to make it fun.

Universidad Espiritu Santo, A Campus where Iguanas and Stray Cats Mingle

A walk home from the University leads to a nightly 1 ½ - 2 hour Spanish conversation over dinner (merienda). Topics include economics, politics, health, food, travelling, current events, my rotations, Mariana’s stressful job, UFO’s……you name it. She is patient and helpful with my broken Spanish.

Watching Holanda get beat by España

Places we visited: Montanitas, home to some of the best surfing in South America, and quite the young Ecuadorian party scene. Cuenca, a town in the hills, with cobblestoned streets, markets, and a hotel with a view of the city. La Bahia, the black market in Guayaquil, where one can find fake Nikes, RayBan’s and Izod Shirts, fresh off the boat from China. More plastic crap that you don’t need than you’ve ever seen before.

Always Choose The Window Seat

2010-06-30T14:11:00.000-07:00

After aforementioned drama, fell sound asleep on the way to El Salvador. Woke up to the sunrise and full moon....

....then thoroughly enjoyed this Costa Rican view...

....and Oregonesque greenery....

Flying into Quito is the best, however. Views of the expansive city, big banking left hand turn, huge plateau with part of the city seemingly just dropping into space, huge Volcan Pichincha towering, airport right in the middle of town. Pilot takes some sweeping turns, working his way into the city and just plops down. As in most places other than the US, the passengers erupt in applause for this and every other landing. Of them all, the Quito arrival is the most worthy of the cheers, chip

The Photo

2010-06-29T13:02:00.000-07:00

The adventure begins before the wheels of the plane leave the ground. After running through the mental list of critical items, I had felt pretty good when Audrey dropped me off at the airport. Despite a weighty duffel bag that was threatening to cost me extra money and a horrendous traffic jam that had me glancing at the car clock every 30 seconds, I made it with an hour to take off and I had the essentials: Wallet, wristwatch, sunglasses, passport, scrubs and tennies.

The sinking feeling came quickly when I swiped the passport under the scanner and it read. “Name Does Not Match Passenger.” Count this as the first time I was disappointed to see my wife’s face. With her smile staring back at me from the passport photo, I knew I was screwed.

Not wasting anytime, I called the owner of this document to see if she wanted it back. And to get her estimate on how quickly she could drive without killing anybody. With the clock ticking, she acted calm under pressure, found her way home, sped through the yellows, looked on the internet for the shortcut to avoid the hour long traffic jam we hit the first time, grabbed the right passport and pointed it for the airport once again. With the plane leaving at 5:30, and the handoff occurring at 5:23, I thought it almost futile to sprint with my shoes untied, laptop in armpit, leaving a trail of funny looks.

The gate people saw me running and I yelled my last name to them and they replied “Run!” which I was already doing. She scanned my ticket quickly then yelled “Run!” at me again as I took off down the ramp. I flopped into seat A18 out of breath, a few new gray hairs sprouting out of my dome. I put my wristwatch on, glance at the scruffy mug on my passport and smile, thinking of the better looking photo in the wrong passport I had been holding 5 minutes ago. Once again, I couldn’t do it without her. Ecuador here I come!

I also brought the wrong camera cord, so you will have to live with wordy updates until I can figure that out...Until then, here is a generic foto de Guayaquil taken from a place I've never been, looking at a place I've heard about.

No Such Thing As Accidents

2010-06-11T11:45:00.001-07:00

A lack of posting has not been for lack of stories, rather lack of energy. I ran into a fellow student who is doing a pediatric urology rotation and we were comparing schedules and hours. When we determined that 80+ hours a week is a bit redunkulous, he encouraged me by saying "but at least you'll always have cool stories...and I just fixed another undescended testicle."

It is true, that the trauma service keeps your inbox full of over the top scenarios that simply cannot be fabricated. Toilet scrubber impalements, hand gun accidents while holding small child, stab wounds, boats and planes crashing, brakes going out on the way to the wedding, the list goes on. While perusing Typhon, the lovely program we use to document all of our patient encounters, I came across an amazing list of actual codes used to describe various incidents. Some of the following are codes that I would not be surprised to use in the last few weeks of this rotation.

E804.3 FALL IN ON OR FROM RAILWAY TRAIN INJURING PEDAL CYCLIST

E018.0 ACTIVITIES INVOLVING PIANO PLAYING

E847 ACCIDENTS INVOLVING CABLE CARS NOT RUNNING ON RAILS

E909.8 OTHER CATACLYSMIC EARTH SURFACE MOVEMENTS AND ERUPTIONS

E876.9 UNSPECIFIED MISADVENTURE DURING MEDICAL CARE

E885.1 ACCIDENTAL FALL FROM ROLLER SKATES

	E920.3	ACCIDENTS CAUSED BY KNIVES SWORDS AND DAGGERS
E965.7		ASSAULT BY LETTER BOMB
E985.7		INJURY BY PAINTBALL GUN UNDETERMINED WHETHER ACCIDENTAL OR PURPOSELY INFLICTED
E995.4		INJURY DUE TO WAR OPERATIONS BY UNINTENTIONAL DROWNING DUE TO INABILITY TO SURFACE OR OBTAIN AIR
E928.0		PROLONGED STAY IN WEIGHTLESS ENVIRONMENT

Sorry, formatting is the first skill to go........






	As my preceptor likes to say, "You can't cure Stupid."

Totem

2010-05-31T16:11:00.000-07:00

This post comes from 2:35 AM in the Resident Lounge of a large hospital. The TV is cycling through SportsCenter reruns and the hallways are quiet. Tonight, less active bowel sounds from the belly of the beast known as the ER, a far cry from last night's fifteen traumas when I vowed to never again ride a motorcycle, step foot in a boat, or even look at an ATV. I vowed to never drink more than 2 beers, and never go outside after dark. I vowed to come to a complete stop and remove all sharp objects from my house.

Waking up at 4 in the afternoon, will shake any of the previous nights vows, so I drank 10 beers, helmetlessly hopped onto an urban ATV with loose lug nuts and road it the wrong way on a one way street all the way to the hospital, all in hopes that I might be mercifully offed, instead of having to report to duty under the supervision of my arch enemy. To avoid a breach in presumed internet anonymity, I will stop there.

In all honesty, overall, a great rotation so far. Besides the sleep deprivation and permanent location at the bottom of the Totem, things are looking up.

Evening Routine

2010-05-26T16:42:00.000-07:00

My wife wants me to tell the truth....I watch this video before leaving for the hospital every evening.

OK

2010-05-24T15:54:00.000-07:00

The start of week 2 has already begun....I can now navigate the maze of hallways, find the staff bathroom, and participate in the chaos of needles and paperwork of a trauma. Definitely not without a good tongue lashing by a grumpy Attending....and some snide comments by an ER nurse.

You basically are the bedpan for anybody having a rough day.

I'm OK with that. I'm letting things wash over me like an ocean wave...enveloping me for a moment but gone in a matter of seconds. I remind myself that the light is appearing at the end of that hallway. And I tell myself that It Is Better To Learn The Hard Way Than To Not Learn At All. (which surprisingly has never been quoted before).

There are other reminders that I am doing OK, relatively. Unlike my recent patients, I have not:

Been stabbed 22 times in the chest by significant other....

Fallen off my ATV after 10 beers and no helmet....

Fractured my sella turcica after a skateboard crash.....

Filled up my ostomy bag with blood 3 times before passing out.....

Gravity

2010-05-21T14:06:00.000-07:00

First day awkwardness is present in most rotations, meeting new people, learning where to park, arriving overdressed, etc. In the trauma in-patient rotation, this is exacerbated several times over, as there are countless angled, empty hallways to navigate, hundreds of buzzing and beeping rooms, a cadre of residents, attendings, other students, trauma and ICU nurses, and various other staff who know exactly what their niche is.....while on Day 1 your role is as clear as the substance in that bedpan.

Thrown into the fire in the first few hours, I am told to go see a patient with a fever, post-op, after ORIF of L ankle fx s/p MVA. I remember my five W's, but before I can impress the PA too much, we get called to a trauma and I miss horribly on a radial ABG. Fumbly, sweaty hands amidst a buzzing room of people. Wires and bags and meds and IVs all orchestrated over this supine victim of a slipped car jack, resulting in a car landing on a chest. But the sweaty PA student can't get the ABG. The next trauma, a 4 year old girl who fell out of her 2nd story bedroom while playing with brother, has very minimal injuries but I play it safe and hang out in the corner, a little gun shy. A general surgery consult, and some hikes over to the ICU, and medical floor.....I leave the hospital completely exhausted, completely intimidated, and completely desiring to NOT work in a hospital.

Like the law of gravity that brought the car upon the man's chest and sent the girl hurtling down to her own lawn, there is a law that states that all Day 1's suck. All ABGs will be missed, and all thoughts of competence will be flushed down the toilet in the only clean staff bathroom (that you can't find). Gravity is the force of attraction that brings tangible objects down to earth (at 32 feet per second), but ego and confidence are also lowered to the ground....sometimes much quicker.

Caj Mahal

2010-04-19T18:50:00.000-07:00

6 weeks off to complete a systematic review (a.k.a. thesis, capstone project, master's hoop, the paper, the project, the PICO, the vacation, the procrastination....)

Call it what you will, but I am thoroughly enjoying my break from khakis and business casual wear. I'm unshaven and wearing flip-flops. I can see my wife from where I am sitting.

Anyway, oh faithful readers, this blog will likely be taking a hiatus, unless I come across some really interesting paragraphs about "the off-label use of prazosin for sleep disturbances in noncombat related PTSD" and feel the urge to share.

Otherwise, check back in a few weeks for a more reader friendly topic....My trauma rotation in downtown Portland.

Recommendations, Cont.

2010-03-19T11:03:00.000-07:00

A few more recommendations, on the lighter side:

If you lose the spacer for your 2 yo daughter’s inhaler, please call us for another one instead of spending over 1 week spraying the medicine into your own mouth then trying to blow it into your daughter’s mouth like some kind of weird backwards asthma CPR.

If your IUD mysteriously falls out, please don’t mysteriously place it in your urethra. That’s not where it goes.

Can we please get back on track after discovering that you and I went to the same high school in Ohio, albeit 20 years apart, which yes is a bit weird, but we can’t spend 15 minutes discussing it, if you also want your olecranon bursitis drained with this needle I am wielding.

When I meet you in the hospital on rounds for the first time can you please not say that you saw me in your dreams last night so we can avoid the weird creepiness of you being a 52 yo mustachioed man who lives with your mom and me just being here to listen your lungs before lunch.

4 days left of this rotation. Can I please have a 6 week break? I need it.

A Case Study of Lactic Acid Buildup.

2010-03-14T17:23:00.000-07:00

I'm Tired.

Recommendations

2010-03-12T08:04:00.000-08:00

I recommend tummy time to increase abdominal muscles for the 7 month old struggling to sit upright. But apparently it is hard to find space for the luxury of tummy time when you live in a 400 sq ft. mobile unit on an orchard, the floor scattered with dirt and pesticides, dragged in from the field.

I recommend taking the insulin and Metformin we prescribed to the 60 year old diabetic with an A1c of 11.7. But apparently when you cannot read, cannot afford medications and cannot figure out which medicines are which in your sac full of expensive drugs, it becomes less feasible to be compliant.

I recommend some common anxiety and depression treatments, but apparently when both your parents just died in Mexico within days of each other and you cannot afford to go there for a funeral, you cannot afford to buy caskets, and instead of getting to say goodbye, you are stuck in overcast Oregon, it’s easier said than done.

I recommend not shoplifting for your $100 per day ($3,000 month, math whiz) heroin habit. But apparently when your Dad is a meth addict, your Mom is an alcoholic and you really, really, really like the heroin in your veins, it’s tough to keep your hands off the merchandise.

It’s one thing when recommendations fall on deaf ears. If you really don’t care what I say, then fine. Sign here and bring the next one back to room 19. You like the potato chips and TV more than exercise. I get that. Say hi to your pannus for me.

But what kills me is the recommendations that the patient soaks up like a sponge. They desire change. They want the best for themselves or for their children. The ears are not deaf. The instructions flow in and register in the brain. But something stops them from being able to follow through. Enter life’s circumstances. Some would call it an excuse, and perhaps that is true in some cases. But when was the last time you lived as a migrant farm worker? When was the last time your parents died and you could not afford to bury them? When was the last time you couldn’t afford a $4 Wal-Mart medicine? When was the last time you had to steal to pay for a habit that you know is killing you? The sadness in this clinic abounds, though I realize it is not confined to this place or this population.

Trying each day to show up and put myself in the patient’s shoes has been an exercise in futility. I will never know what some of these people have been through. All I can do is show up and listen. And recommend. And then listen some more. And count my blessings: supportive family, adequate shelter, functioning pancreas, and only a very minor caffeine addiction.

Shuffle: Off

2010-02-27T09:22:00.000-08:00

Much of medicine is like listening to an iPod on shuffle. One minute I am interviewing a talkative 73 year old about her breathing problems and long list of medication refills. The next room over, I might encounter a shy 2 year old, clinging to her mom’s leg. Shuffle in some diarrhea, some dental pain, some fancy new medicines with lots of Z’s and X’s in their names and some old school procedures like suturing up a hand. In other words a day can take you from Beethoven to Brittney and back with the knock of an exam room door. The ER is a shining example of this randomness. Things happen, hangliders crash, hearts attack, and the doors are never locked. People come and go all day. And despite the inevitable frequent flyers, most are brand new customers. Like hearing that good song on a shuffling iPod….and never hearing it again.

But some albums just require listening in the right order. Pearl Jam’s Ten or Pink Floyd’s Dark Side of The Moon, for example. Maybe they have a message, certainly they have a flow. Before the days of shuffle, the end of one song would have you humming the beginning of the next, before it started. A certain level of expectation is then satisfied when sure enough, it plays. Life is certainly more random, but sometimes in primary care medicine, while often a day is chaotically scheduled, sometimes it feels like listening to an album in the correct order.

Even as a “short-timer” student, inhabiting the clinic for a few months I have a case in point:

Seeing a pt for her last 2 or 3 prenatal visits, and then following her to the hospital for post term induction. Learning to read her “bad strips”, and then watching her c-section. Doing a newborn exam on her little baby boy, a bit banged up from delivery, with a possible broken clavicle. Seeing everybody back in the office a few days later for a weight check, then assisting with his circumcision a few days after that. I could anticipate the next song. If I hung around for a few years, I could anticipate a few colds, maybe some asthma. Lots of shots. Throw in a broken arm from snowboarding, some questions about puberty, and a weird rash. If I hung around for a few years after that I might anticipate some low back pain, a consult to an expert in Portland, and some advice as he starts his own family.

So while an individual day might have that feeling of shuffling through 20 gigabytes, the overall picture has an underlying rhythm. And while, impossible to truly anticipate the next song that will arise in a patient’s chart, just experiencing the album in order is satisfying.

Heart Medicine

2010-02-05T08:13:00.000-08:00

Dried mud clumps start in the hallway and lead into the exam room, where I find two men sitting. The first is a heavy set Hispanic man, with bulging arms and chest likely from a life of hard work. Just south of the muscular thorax is a similarly bulging abdomen, this likely from a life of hard eating. He wears a tight generic Wrangler shirt that appears to want to pop. He is round, but strong. Saying his name, “Rolando”, I shake his calloused hand and offer, “mucho gusto.” He eyes me with distrust, but that’s OK.

I turn to the man sitting next to him, an Anglo. He is tall, with thin gray hair. His skin is tan but Anglo tan. He spends a fair amount of time outside, surely. He wears a zippered fleece and while his boots are also contributing to the trail of dirt, his jeans are new and clean. He’s el patron, the boss. “Mucho gusto, Jeff.”

Sorting through the history and the reason for the visit is the first challenge. It is generically listed as Health Maintenance Exam, but the patient immediately launches into… Chest Pain. Pressure. Aqui. When those words are spoken they seem to just float there, waiting for me to attach them to something. My heart rate rises. I scan his chart and after a few more questions, understand that he suffered a heart attack in November and presents for continued angina. Worsening. When he walks in the house. When he does dishes. Pressure in all the places you don’t want pressure. Radiating to all the places you don’t want radiating. But at least the initial Chest Pain. Pressure. Aqui. is attached to something. I can slow down.

Jeff wants to know when his employee can get back to work. I want to know when he can get back to a cardiologist.

I’ll admit my initial thought was that this orchard owner was just trying to get his “help” back in the fields as soon as possible, despite the consequences. I assumed he just wanted medical clearance for Rolando so he could enforce a return to hard work. I couldn’t have been more wrong.

It turns out these men have known each other for over 25 years. They consider each other friends. They know each other’s families. Admittedly, there is a lopsided role of power, finances, and access to healthcare. One owns thousands of acres and (like me) probably pays somebody to change the oil in his car. The other is a poor immigrant from Mexico with ill-fitting clothes and no car. But what’s not lopsided is Jeff’s evident compassion for Rolando. He wants to make sure no further damage is possible to Rolando’s heart, while at the same time helping get him out of the trailer that he is trapped in, a prisoner to his chest pain. He wants to advocate for his employee, helping him get a cardiologist appointment. He will drive him to Portland. He is helping with the cost of expensive medications and consults. While miles apart in their background, today finds them sitting next to each other in an exam room. And in the end, they both have mud on their boots.

We were able to increase some medications that will likely extend the exertional capacity of Rolando’s heart. Not in heart failure, the problem exists in the coronary arteries, not the pump itself. He has a stent in one of the offending arteries, but another one was, for lack of a better term, unstentable. We gave our blessing to try some work, as tolerated. Stay off the big tractor for now. With close follow up, we will see if the medicine change helps him.

But Rolando may eventually need a bypass, meaning open heart surgery. If he does, I suspect that in a hospital in downtown Portland there will be two sets of muddy boot tracks, where there might have only been one….or none. And that is the heart medicine that might be the most important.

Best Reason to keep a Brightly Colored somewhat Sporty Looking Jacket in your Car in One Sentence or Less.

2010-02-02T08:20:00.000-08:00

So when you are travelling through windy* and windy* but gas-station-less Columbia River Gorge at a high rate of speed on Monday morning trying to make it to work on time and you suddenly notice that your gas-light-less car is on empty and then 3 minutes later realize that you are sputtering to a halt on Interstate 84, you can put this jacket on and represent yourself as an obviously not crazy one-toothed psycho hitchhiker and make yourself appear as a much more benign skier or PA student in distress, so that this one guy will pick you up and drive very fast to Hood River without functioning seatbelts in his car and then this couple with a rental car with Ohio plates and rental skis will pick you up and take you westward to your car, thus making it possible to still make it to your cold rental house, shower, shave and make it to work with 4 minutes to spare.

*windy as in breezy
*windy as in curvy

Self Titled

2010-01-31T16:20:00.000-08:00

I describe to my preceptor the perfect viral pharyngitis. Not one single symptom of strep throat. No fever, no lymphadenopathy, no “painful swallowing”, not in the age range that would increase suspicion, no tonsillar swelling or exudates. There is the perfect history for post nasal drip with cough and no contacts with strep. My description of the throat rivals a text book of what Strep Throat Doesn’t Look Like. I won’t bore you with details.
“So we’ll just do a rapid strep test and send them on their way.” says my preceptor, apparently unconvinced. He is unsure of why, so I help him out. I validate the possibility of a strep test, noting this could be a “therapeutic” test. In other words, a lab test that may help assure the patient that a bacterial organism is not causing her pain. It may provide some relief to know that we did everything possible to find a reason to give her antibiotics, even if she walks home empty handed, despite the evidence that gives her a next to zero chance of having strep throat. He then needs a glass of water so we spend 10 minutes in the kitchen while he lectures me on the point that I just made for him. It is a cheap test and if everybody sleeps better tonight then so be it. But, in order for her to sleep better tonight, we have to get her out of our office before midnight. Put the water glass down and let’s do something, even if that something includes doing a test that I can guarantee will be negative.

I gag the patient with a swab and send it to our lab. Alas, it is negative. (If it had been positive for strep, I would have been devastated and probably too embarrassed to relay this story to you.) I then wait, and wait some more, for the preceptor to be ready to go see the patient. A 15 minute visit turns into 45. He’s been frustrated all morning, slow in his pace and deliberately making things like being put on hold, or logging into his computer seem overly dramatic.

We shuffle into the room and I listen to my preceptor describe viruses, post nasal drip, and the lack of need for antibiotics. The mother of the patient tells the tale of being prescribed antibiotics in the past for similar episodes. Not today, honey. We offer symptomatic relief.

After we’ve left the room and the patient was left with her salt water gargling instructions, my preceptor turns to me and in a demeaning tone says, “I certainly hope you won’t be one of those providers that prescribes antibiotics for that in the future.”

“You got it, pal,” I think as I watch the family leave, well over an hour after they should have.
Funny moment when you realize that, despite not knowing it all, or even not knowing a lot, you still develop your style of practicing medicine. Mine is different than his. Or maybe I just don’t like him.

New Guy Once Again

2010-01-09T12:31:00.000-08:00

First week of 3 months in Hood River completed. I'm renting my own house close to downtown. It has a wood burning stove but no WiFi, so I bought a 1/4 cord of wood and will likely spend more time stoking the fire than surfing the web.

A very different feel here compared to Cheha-town Peds. There it was fast paced, 2 minute dictations, crack-the-whip, sort through the viruses medicine. My patient presentations eventually got boiled down to: "It's diarrhea. They look good." Even in Scrippsville, if they walked in the door they got a Statin. A door prize that didn't require much thought or reason.

My preceptors here expect a much deeper and wider differential diagnosis. They also expect a little more evidence based approach. We actually use things like Framingham's Cardiac Risk Score. They want my notes to say things like "...due to lack of abd pain and blood in stool, we ruled out bacterial etiology of this patient's diarrhea although if symptoms persist we may order fecal leukocytes and occult blood studies." Their ortho exams entail more than their fingers hitting keyboards to order an ortho consult.

It's refreshing. And difficult at the same time. It's easier to practice loose and fast medicine and blame everything on how busy your schedule is and how the "real world" doesn't include a legit review of systems and lengthy differential. It's easier to keep the patient's sweatshirt on and call a specialist than to actually examine their shoulder.

And at the same time 85% of my patients speak only Spanish. So my brain is doing a bit of spinning right now. I am being humbled on multiple levels. From basic communication skills (come se dice 'blister' en espanol) to detailed pimping (what are the guidelines for phototherapy in newborn hyperbilirubinemia?)

I'll keep you posted. But for now, I'll be stoking that fire with a textbook on my lap. I've still got a lot to learn.

Little Moments in a Big World

2009-12-15T17:36:00.000-08:00

Interesting Moments in Pediatric Medicine:

Realizing that pediatric nurses, despite their teddy bear scrubs, will cuss, smoke cigarettes, and make fun of whiny kids behind their backs.

Picking up a previously undiagnosed heart murmur during a visit for vision change. And being reminded why I listen to the heart and lungs in every patient every time.

Realizing that kids actually are hoping that the X-ray will show a fracture, as it is a much cooler diagnosis than "contusion".

Being asked by a teenager to explain to him what a MILF is. And going for it, with the blessing of the parent and preceptor.

Telling a mom that her son's "Gait Disturbance" is because he is wearing shoes that are twice the size of his foot, and loosely tied. Rx: Nike Outlet down the road.

My wife "stealing" the prized quilt from the Clinic Owner in the Christmas Party Gift Exchange. And watching my evaluation go down the tubes.

Realizing that the child who cut the tail off the family dog and stabbed a teacher with scissors then repeatedly punched self in face until bleeding, and is now in handcuffs, foam helmet, 4 point harness seat and spit mask needs to have my fingers near his mouth, just as the guards tell me he likes to bite.

Referring for evaluation for medical marijuana for chronic pain.

Pneumothorax in a 6 hour old boy.

Still not understanding the whole immunization schedule. Thank God for the aforementioned pediatric nurses. Despite their sailor-like attitudes, they can certainly help me decipher the IPV,Hep,VZV,PCV,MMR,HIB,DTAP,TDAP madness.

Having the moment of clarity, which led me to utter the words, "I could do pediatrics...."

Can't Beat the Odds

2009-12-04T19:04:00.000-08:00

I officially can now be lumped into the "every student that comes to this clinic gets sick" crowd. I thought I was going to go unscathed. I heard the statistics. I knew nobody had ever made it 6 weeks with a clean bill of health. I had my daily vits, my 2 daily clemintines, my cat-like reflexes for dodging respiratory droplets, and various other "jump the chalk line" superstitious, knock-on-wood type methods of evading the virus. I even washed my hands a few times. In other words, 079.99

On a side note, I thought I experienced my first earthquake last night. I woke up to the bed

shaking, the walls vibrating and an overall bumpy feeling in the room. My first thought: Chris (geologist brother) is going to be so impressed. My second thought: Is Chehalis even near a fault? My third and final thought: Why did my landlord just start their dishwasher at this hour?

They apparently own the 1973 model that has such an intense cycle, it is a threat to the structural integrity this house and my patience. I think a quake would have been milder.

High Points

2009-11-21T17:35:00.001-08:00

A decidedly non-medical post. After 2 weeks of seeing 20+ sniffly kids a day, I am little burn out. Would rather post some photos of decidedly non-medical trips we've taken over the last year in a half. So here is a Northwest Volcano Pictorial:

Mt. Adams from a fire lookout

Mt. Baker from a ferry

Mt. Hood from a ski tour

Mt. St. Helens from Mt. Adams

Mt. Adams after our car almost almost caught on fire.

That's all. Will now resume regular programming as scheduled.

Rising Waters

2009-11-17T21:58:00.000-08:00

9am-5pm Day Clinic; Saw twenty kiddos in varying states of stress, illness and general outrage toward me and my otoscope.

6pm-9pm Night Clinic; Saw seventeen kiddos with varying degrees of vomiting, diarrhea, and general fluids erupting from orifice.

10 pm Home in Cold Attic; I learn that the waters are rising on the Chehalis River and the Newaukum River. River will reach flood stage tonight or early tomorrow a.m. Interstate 5 may close which would prevent me from getting to the clinic. Apparently if the Skookumchuck River gets to Phase 2 (not that high) then I will not be able to leave the house, as the small Dead End street I live on will be surrounded. At least I live in the attic.

Photo from Today's Lewis County Newspaper

Breathtaking

2009-11-15T14:27:00.000-08:00

Nurse Practitioner (NP) student comes barging in out of breath, late on her first day. To be fair, the fact that she is an NP student doesn't mean anything. She could be a PA, MD, DO, PT, MA, or MSW student. She could be a law student or a MBA student. I don't care. But, truth be told, she is an NP student. And she is a train wreck.

Within 10 minutes she is already starting an argument with the PA about how much better NPs can and will be because they can practice independently.

Within 20 minutes the clinic staff have all heard how amazing she is and how much vast experience she has as a nurse, including how many IVs she has started in her life.

Within 35 minutes, I begin to wonder why she is still out of breath.

Within 36 minutes, I realize that perhaps she is out of breath because she is about 6'1, 260 lbs, built like a linebacker that doesn't do any linebacking anymore. I think she has COPD.

Within 2 hours, I have learned that she owns 5 boats, owes next to nothing on her house, and is for the most part the master of all things disease. At this point, I begin to think she is just out of breath because she never stops spewing words out of her trachea. Her poor vocal cords are too busy vibrating to let in some good old Room Air.

Within 11 days or so she will be gone, as her program only requires 90 hours per rotation. I will stay for another 20 days and 150 hours. But then again, I am not the master of disease. And I don't even own 5 boats.

Attics and Locusts

2009-11-12T20:40:00.000-08:00

I find myself alone in a cold attic bedroom, in a strange town halfway between Portland and Seattle. Life as a traveling PA student, at the mercy of the next clinic, the next preceptor, the next dress code, the next temporary landlord, the next temporary landlord's water heater.

Can't complain too loudly, as I've got hi-speed wifi, a roof keeping out the incessant Washington rain, and plans to drive back to Portland tomorrow. Saw my first kid today who was born with meth in his system. Now there is somebody who could reserve the right to complain. His insides don't work so hot.

Shared the clinic with a NP student today. Wow. That is all I am saying for now. If I give it a few days, I will have material for miles.

On a historical note, this is my second rotation in a rural county seat. The first one was known for a Great Fire. This one apparently had a Great Flood. I feel like I am on a tour of modern day Plagues. If my next rotation has locusts or frogs falling out of the sky, I'm done.

Sin Numeros

2009-11-11T09:39:00.000-08:00

"You guys and your numbers...", Audrey says after skimming my blog, something she claims to do anytime there is medical jargon or numbers involved. It is true that my audience is likely a mixed bag: A few fellow students that may think it's neat that I saw a twelve year old with pulsating pupils with adrenal insufficiency and some family or friends that just like updates assuring them that I am not locked up in a Tijuana Jail.

So, for the mixed bag I try to bring a mix. I may write "UTI" one day and "bladder infection" the next. I am a little biased to "UTI" because: a) it sounds like I know what I am talking about b)it is shorter to type c) it's less gross then "bladder infection". Funny how the laymen term is more descriptive, a little more "in your face."

Heart Attack = MI
Anal Warts = Condyloma acuminata
Patient wants to Kill Herself = Suicidal Ideation or SI.

I'd rather have Condyloma twice then anal warts ever. I could go to the Walmart Clinic for an MI, while I may need an ambulance for a heart attack! People see SI and think you have a nice magazine subscription, not a need for anti-depressant prescription.

So I walk the balance of not freaking you out, not boring you to death, and not sounding like a total dork. So you will notice not one single number in this post. I even typed out the word "twelve". Enjoy, because tomorrow we may be back to statistics, percentages and other not-so-titillating minutiae of medicine.

Oh and I watched a circumcision today. Which is medical jargon for strapping a baby to a board, stabbing needles in and around the groin, slicing, dicing and removing his foreskin, and leaving behind a bloody penis, then handing the baby back to the Aunt, because the mother is too freaked to watch any of it, and you don't blame her.....see it's just easier to type "circumcision".

Day 1 Again

2009-11-09T20:42:00.000-08:00

First day, continuing with some more numbers....

7 viral URIs, ages 2,3,4,6,6, 7,11

2 ear infections

1 strep throat. I love the Centor Score.

19 yo F dysmenorrhea. Preceptor was surprised she would talk to me.

18 yo F tooth pain. Get a dentist.

11 month old new patient for the HinnyVax

17 yo F "Influenza A" , orthostatic, dehydrated, IV start, first one in a while. She was too lethargic to care. Just like my first IV ever, oh wait he cared but he was just wearing handcuffs.

Unlike internal medicine these people are young and "under-medicated". The drug rep sharks could be circling outside the clinic. Fast, fun day. Oh and the somewhat creepy picture below are not my patients, but a visual clue for anybody that didn't realize I am now in my pediatrics rotation. I promise no more blooming christmas tree shaped pediatric poster children.

Numbers

2009-11-08T10:35:00.000-08:00

Rotation 4 by Numbers:

Miles Driven: 3,358

Patients seen: 182

Tamiflu Prescriptions Written: 1

Patient’s with Dengue Fever: 1

Vaccinations Given: 0

Vaccinations Received: 2

Visitors: 3

Combined years knowing the 3 visitors: 75

Surf Sessions: 41

Fish Tacos Eaten: 8

Leopard Sharks Swam With: 54

Incidents involving lacerations: 2

Sutures Received: 7

Rotations Sites Left: 4

Pediatrics is next…on to the 7 year olds, after a rotation full of 70 year olds! Ears, rears, and mother's fears here we come!

TJ

2009-11-04T18:16:00.000-08:00

After a great visit from brother Chris, there was only one thing left to do. Vamos a Mexico! Turns out, I should have taken Cialis orders for a few patients.

Against the advice of my preceptor, I walked into Mexico, alone. Last time they gave me a Wednesday afternoon off, I returned with stitches, so I understand the hesitation. But a two hour stroll across the border simply provided lots of family friendly entertainment. I was offered Vicodin at least 8 times, among other various legal and not so legal substances. One hombre called to me "hey guy my friend I have what you are not looking for." Exactly.

Felt the endorphins kick in with the sound of Spanish, the ripe smell of diesel exhaust mixed with garbage, the sight of rifle-wielding cops, the awareness that I was the foreigner. Smiled at the hucksters and the cabbies and the pharmacists. Love the way people drive and honk, love the music blaring from each empty cantina and love the mariachi band members getting their shoes shined on an otherwise boring Wednesday afternoon. Spent exactly one american dollar while here, on a Tecate. It was cold, refreshing, and funny how they always taste better south of the border.

Got back to los estados unidos in time for an evening surf session.

Now I am officially ready to head North. Get me out of here.

A Break but not Broken

2009-10-26T16:53:00.000-07:00

A longer than normal hiatus due to:

A long period of "work-surf-work-surf-work-surf..." gets a little old rubbing it in to all of you land-locked who don't get to taste the salt of the sea on a daily basis. Also not much to report at the clinic other than..."I actually kinda like it..."
A lack of internet preventing me from sharing up to the minute updates on my laceration sustained while surfing large Hurricane Rick affected swell. 7 sutures in my forehead and a whole boatload of crap from the clinic personnel later, I am in a state of recovery with a long modeling career ahead of me.
Audrey visiting...so all communication goes on shut-down. We snorkeled in the clear blue water, kayaked with sea lions, ate amazing mexican food, drank NM's potent margaritas, and *watched* the non-wounded surfers do their thing at all the right beaches.

I hope this finds you all well, in good spirits, free of head wounds, with belly full of your favorite fruit or vegetable. See you Portlanders soon.

LA,CA

2009-10-06T20:46:00.000-07:00

Went North this past weekend to catch the final regular season Dodgers game. If they hadn't won the night before it would have been a very important game, to decide who won the NL West. But they were post-clinch, so the game was less important than the atmosphere, which was one of laid back celebration. L.A. has (at least) 3 former Cleveland Indians with Manny Ramirez, Casey Blake, and Jim Thome, so I felt OK about rooting for them. Plus I've never been a fan of any Denver teams, so to watch the Rockies lose was satisfying. Thanks Sean's Mom and Dad for the great tickets!

Back to the clinic for week 2. It has been a good mix of chronic care, acute complaints, thick charts and simple bee stings. I thought I could fend them off, but after 3 drug rep free rotations, the henchmen for the likes of Pfizer, et al have found me. They come bearing breakfast, lunch, and afternoon coffee and snacks, so as a poor hungry student I fell quickly to their methods. I am currently working on my strategy to increase the free food : jabber ratio.

Week One in Cali

2009-10-01T21:29:00.000-07:00

Here are a handful of pics I grabbed this week:

The drive to Southern California was both beautiful....

...and typical.

My local surf break has it all: close parking, rip current for easy access to the outside, a pier for people watching when waiting for the next set (and for watching the true rippers "shoot the pier" which essentially means hurling yourself down a wave on a surfboard toward and through the concrete girders of the pier.), friendly locals that accompany me in the water late into the evening, and a lively apres surf scene with bustling restaurants, bars and a farmer's market on the street 2o yards from the beach.

The morning view from the kitchen as I eat my banana have been nothing less than spectacular. You gotta click on this pic for better detail:

I am not the only one who commutes with a surfboard:

No photos available from the clinic, but imagine if you will, me in a white coat with salt water in my ears, running around a small clinic in a big hospital attempting to eliminate disease, one lipid panel at a time.

Sandy Eggo

2009-09-28T22:39:00.000-07:00

I actually thought of calling San Diego, "Sandy Eggo" while out surfing this evening after work. I googled it to see if I was original. They already have sweatshirts made. Google had 58,00 hits for it. In fact, I think it may have actually been the original name for this city, before they changed it to San Diego. Further proves my point that hardly any thoughts are original these days. People do everything, all the time. It's just go, go, go in this world. Hard to keep up.

Anyway, I'm here. Haven't seen any waffles on the beach yet. But it would be a nice place to have breakfast.

Plan by Pictures

2009-09-24T18:43:00.000-07:00

My Plan for Tomorrow in Pictures:

1.Wake up, shower, eat an egg and toast and drink french pressed coffee.
2. First assist on a breast lumpectomy, an inguinal hernia, a needle localized breast biopsy, and a laparoscopic appendectomy.3. Tell you that I chose such a benign picture of an appendix because it reminded me of waves.
4. Bid farewell to Roseburg and head through the State of Jefferson, on my way to Southern California. Click the term "loony bin anti-government die hard extremists" to learn more.
5. Arrive in Montos de Los Altos de los Palos (or something like that), where Connie my Roseburgiean Landlordess has an Crazy Aunt who will put me up for the night. Only caveat is she smokes like a chimney and requires at least two bottles of Red Zinfandel per visitor. Something tells me she will have cats. Lots of cats.
6. Rest for the final leg of the 17 hour drive to San Diego. Where the waves will giveth, the skin will bronzeth, and the medicine will be internal. Whatever that means. See you there!

CA

2009-09-21T21:21:00.001-07:00

The sickening irony of growth causing death. Cells out of control with multiplication causing subtraction of health.

I've seen it.
A cousin lost as a teenager, the fear of recurrence in the eyes of an imprisoned man. The metastasis to the liver shining bright on a CT scan. My mother finishing up her radiation treatment in Boston.

The phone call that you don't forget.
The scrambling through websites that it prompts.
The numbers, statistics, percentages flying at you like bullets.

Then more irony in the way we fight it. Chemicals and radiation used to fight something perhaps caused by the same. Intangible hope and prayers directed at all-too tangible cells.

The fight that it requires but the calm that it demands.

The way it hits you. And the reaction that collision sets off.

I'm proud of you Mom, et al.

Contradictions are Contraindicated

2009-09-16T16:55:00.000-07:00

In the art of medicine, when something is contraindicated, it is a good idea to not give it, perform it, prescribe it, or do whatever you are not supposed to do with it. The "it" may be a drug, a procedure, or an otherwise benign substance or activity. We avoid contraindications like we avoid lighting ourselves on fire. Makes sense, right? I'd don't like being on fire. That's why babies don't get aspirin, viagra and nitroglycerin don't mix, and ummm....pregnancy and parsley are evil together.

In the art of politics, contradictions float around like oxygen molecules, inhaled and exhaled on a daily basis, without a care. A few:

Government run health care would be so inefficient....but......it would be too good and put all the insurance companies out of business. Which one is it?

Americans have plenty of access to health care (A.K.A Status Quo and the GWB "Just Go To an Emergency Room Plan")....but....if everybody gets insurance then our doctor's will be too busy! If "everything is fine" then why would stirring the pot, so to speak, stir up an *overwhelming* amount of people who need help? "Republicans opposed to sweeping reform say the health care system would be overwhelmed if nearly 50 million uninsured Americans are given coverage"---Associated Press

This health care thing costs too much....but...$900 billion in Iraq and Afghanistan (resulting in 5,000+ U.S. deaths), is just fine.

"Christian Right Largely Opposes Health Care Reform" .....but.....There's This.

Perhaps these contradictions should be contraindicated in a worthwhile discussion about health care. Pick your stance and stick too it. Disagree with your neighbor, that's OK. But don't change your argument with each new sound bite on the inflammatory morning talk show. Like giving a cigarette to an asthmatic, tossing around contradictions should be ill-advised.

It was only a matter of time before this blog made some inciting statements (not to be confused with insightful). I apologize, and will soon be back on track, reporting on life as a PA student. To smooth things over, I offer this Old-School Nintendo Game that we can all agree was pretty sweet. It is only Contraindicated in those with ADHD and Seizure Disorder.

Just One of Thousands

2009-09-15T20:16:00.000-07:00

Once again, the 2.5 hour drive up to Portland from Roseburg is worth every cent, every ounce of gasoline. Amazing weekend in the city: From eating Moroccan food to getting beat by Audrey at tennis. From watching the above birds do their yearly migratory dance at sunset to seeing Weinland play a few blocks from our house.

Back south to Gallbladder Land. Next time I am going to keep heading south, until I hit the border of Old Mexico. Then I will go back north a few miles and plant myself within sight of the sea and start treating people with medicine, instead of just yanking body parts out of small holes.

CA

2009-09-11T00:02:00.000-07:00

The sickening irony of growth causing death.
I've seen it.
A cousin lost as a teenager, the fear of recurrence in the eyes of an imprisoned man. The metastasis to the liver shining bright on a CT scan. My mother finishing up her radiation treatment in Boston.
The phone call that you don't forget.
The scrambling through websites that it prompts.
The numbers, statistics, percentages flying at you like bullets.

Then more irony in the way we fight it. Chemicals and radiation used to fight something perhaps caused by the same. Intangible hope and prayers directed at all-too tangible cells.

The fight that it requires but the calm that it demands.

The way it hits you. And the reaction that collision sets off.

I'm proud of you Mom, et al.

Four Thumbs Up

2009-09-09T18:12:00.001-07:00

2 for Inglourious Basterds, Quentin Tarantino's new film, which I indulged in last night after getting off early from work. It was our anniversary, so I honored the event by watching a movie that she would never in a million years sit through. (See, this frees me up for a future chick flick, when we are reunited.)

2 for Obama's healthcare speech that just ended. Again, a slow day in the OR early allowed me to go to the library and stream it live on CNN. I hope you had a chance to watch it also.

The Do's and Don'ts of a Roseburg Surgery Rotation

2009-09-03T17:57:00.000-07:00

Don't live with a crazy lady with 2 kids and an untrained dog in a messy house unless you really want to spend the entirety of your evenings in your weird room that is decorated with strange bear paraphernalia, which includes but is not limited to, a life size black bear dressed like a fisherman. Do make friends with the bear.

Do be prepared to nod and smile at the small talk in the break room, which generally revolves around comparing Obama to Hitler, adding up how many handguns one has (and losing count), or bashing people who recycle. Don't bring up health care reform.

Don't walk into the OR without your mask on. If people start waving in a circling motion around their mouth, with a disgusted and hateful look in their eyes, Do take that as a sign that you are missing something.

Do learn the proper anatomy terms, however Don't be surprised when the surgeon refers to the "Butt Case" we'll be doing at 9:30.

Don't blog on the net about the wrong-sided surgery that you witnessed a part of. Do remember to tell others about it in person, behind closed doors.

Don't expect a blog from me for a few days. I'm headed to the coast (via Portland) to spend the long weekend surfing with Audrey and Josh. Do enjoy your weekend. Do it now.

Perma-Change

2009-09-01T20:05:00.000-07:00

In the middle of a rotation that won't last forever, like most things. Last weekend in Portland, Audrey and I went on a trail run in our beloved Forest Park. At the outset it seemed like summer still, with blue skies, yellow sun, and green leaves. The primary colors of summer. But in the depths of the shady park, there was change. The brown hue was creeping into the floor and walls of this windy hallway of a route. On some corners, near the dried up creeks, the decomposing leaves allowed a rich, musty air to hang in the nostrils until our fast-paced lungs could exchange it on the next uphill. The next morning we woke up to gray skies in Portland. The day after that it was September. And here I am contemplating Change.

On the drive back to Roseburg, I surfed the FM channels of the Toyota's radio. At one point I drove right into some airtime that was hosting all sorts of great Latin music. Rumba, Salsa, Afro-Cuban, Mambo....and I was soaking it up like a laparotomy sponge. But as my trajectory was southbound on Interstate 5, at a rate faster than most police officers would be comfortable with, I knew the rhythms were not going to last forever. And then, sure enough, before you could say "Tito Puente y su Orquesta", it was gone. Evaporated 15 minutes after it was born.

This rotation won't last either. Though shorter than a summer, and longer than a 4 minute Samba, at times it feels like both. At times, hours fly by, running from case to case. Other moments are stretched slowly out like an outgoing tide, like listening to the surgeon tell the 49 year old man that his metastatic colon cancer gives him less than 20% chance to still be alive in 5 years. In a few weeks, I will be a distant memory to this hospital and vice versa. I will be the new face elsewhere and a new town and a new state and will become my temporary home. You have to like the word "new" to survive this year.

Change is inevitable. You don't need a blog to tell you that. We see it in September, we hear it on the radio, we sense it in the mirror every morning. The question becomes how to interact with this change. For me, I prefer to trail run towards it, tap my hands on the steering wheel with it, pretend to know the words in Spanish for it and scrub in through it. I hope this finds you all interacting with change in your own personal way. Yours Truly, CD...

Mr. Tyrone Laces

2009-08-31T19:42:00.000-07:00

Each morning, after passing through the hospital doors, I avoid the urge to take a left and follow the hallway that leads to the ER. I feel the pull, but fight it, and head straight to the belly of the hospital, the OR. Passing through a few more doors gets me to the inner sanctum: The Surgeon's Lounge, complete with leather wrap-around couches, a large flat screen TV with ESPN on, and donuts. I pause to watch SportsCenter's attempt at making pre-season football seem dramatic. Perhaps I scrounge some donut action. Then I continue a few more steps to grab scrubs, cap, mask, and shoe covers.

That's about where my freewill ends for the day. After that I am at the mercy of the surgeons, nurses, and staff. I hold things when I am told, I let go of things when I am told, I cut things where I am told, I sew things up in the manner that I am told, I follow surgeon's to the ICU when I am told, and I go to the cafeteria when I am told.

Actually for 10 minutes in the middle of each day, I am granted some more freewill in the form of a Salad Bar. I enjoy choosing which cherry tomatoes to plop next to the chosen carrots. I enjoy not choosing mushrooms, opting instead for chopped egg.....

Then it is back to reality. I am told when to stop eating and when to head back to the OR. I am even told when to be told.

So far I think I am doing a pretty good job of doing things when and how and where I am told. But is it a problem that it took me 20 minutes to tie my shoes this morning because I sat there staring at them for 19 minutes waiting for somebody to tell me to tie them?

Horse vs. Wasp

2009-08-26T10:18:00.000-07:00

"Can you come to my place and ride my horse once a week while I recover from this surgery?" asks the rancher with diverticulitis and a fistula (connection) from his colon to his bladder, causing frequent infections and air to be expelled from his penis.

"I also have a beautiful daughter, but she's as ornery as a wet wasp," he says trying to sweeten the deal to the young (appearing) PA student who has to take his wedding ring off for surgeries.

I almost take him up on the non-ornery horse riding half of this offer, as I picture myself saddled up, trotting around the Oregon foothills with a piece of straw dangling from my lower lip, or maybe a Marlboro. I could trade in the scrubs for Levi's, the frigid operating room for the August sun.

Then he starts talking about hay bales, heavy lifting, and general barnyard type work, and I decide to just let the ornery daughter get her hands dirty for once and help her poor rancher-dad out.

Croakies, stat.

2009-08-24T12:56:00.001-07:00

OK enough about the destination. Despite my assessment of this town and my unending search for the perfect place, this rotation is actually about surgery.

Lots of gallbladders, hernias, breast biopsies, and colonoscopies. First part of the week it was a lot of watching. The HR people were not convinced that my negative TB test from May meant that I didn't have tuberculosis. They wanted to feel no induration for themselves. Once they did, I was allowed to "touch patients", as the lady put it. That's good, I thought. While shadowing this whole time, I have been breathing on them. But never mind that TB is transmitted by air droplets. As long as I don't "touch" them.

Once I was allowed to scrub in, TB-free, things got more interesting. I basically act as the first assist on all surgeries. I stand across from the surgeon and hold retractors, suction fluid, and cut knots. Only once did I contaminate the entire sterile field and the patient by having my completely unsterile safety glasses drop off my head onto the patient and the drape. I followed this with a short expletive and a thorough apology. I was glad to not get kicked out of the OR and they told me they would get me some croakies.

Other fun moments:

Holding a gallbladder in my hand
Totally sucking at the subcuticular suture
Watching the surgeon sort through small intestine, like so many sausages
Eating PB and crackers for lunch as I chase the surgeon through 13 cases in 12 hours
Having today off, after a really fun weekend with Audrey, exploring all the places from the previous post (a trip that may deserve it's own dedicated post, and may be found soon at chipandaudrey.blogspot.com)

Rose Colored Lenses

2009-08-24T11:35:00.000-07:00

To catch up a bit on the last few weeks of bloglessness:

I finished my prison rotation with mixed feelings. Overall very good experience to have so much autonomy, have a fun classmate to share the ups and downs (and the 1.5 hour drive) with, and great to be living at home and seeing Audrey every day. But for the most part, Tom said it best: "Its time to move on, time to get going ..."
Had a week of "class" which was a nice vacation. (Stayed up past 8:30 pm on more than one occasion!)
Onward to Roseburg and a rotation in surgery. This town of about 20,000 has potential written all over it. A nice historic downtown, a river running through it, free concerts in the park (I drank beer with the surgeon and an anesthesiologist as we listened to Susan Tedeschi), and a veritable hotbed of recreation opportunities in the nearby Upqua River corridor. For example....Not to mention the whitewater kayaking, an 80-mile hiking trail, proximity to the Pacific Ocean, and the arid climate (compared to soggy Portland.)

This place is destined for an Outside magazine exposé entitled "America's Top 10 Secret Towns You Should Move to Now". You know the article. We've all read them. Where is the next cool place? It's too late for Telluride, CO. It's over for Burlington, VT. Bellingham, WA? That's so 7 years ago. Authors dig deep these days: Salida, CO, New Paltz, NY, Boone, NC....Enter Roseburg.

But something is just not right. Like many of the obscure locales, there is a reason why it remains a secret. The economy here seems like a sinking ship. Vacant storefronts outnumber the operating businesses. A Friday evening in the historic town center reveals an eerie silence. An aging population may keep the hospital busy but the overall vibe here is one of decay. The new subdivision I reside in has halted construction. The developer brought his cows down to the pasture that was supposed to house new homes. The coffee shop is only open Monday through Friday. Time will tell if this town can truly become an Outside Magazine posterchild. Or will remain the impoverished Douglas County Seat, with bad schools, no jobs, and vacant storefronts? Either way, the river, the mountains and the lakes will be here when you arrive.

Scratch Marks

2009-07-31T18:58:00.001-07:00

Been slow on the blog. 106 degree afternoons and hot laptops don’t mix. 1 week left of this rotation. Don’t really type in full sentences any more. Interesting habit. Lazy. Hot.

Amidst the average, have been a few noteworthy patients in the last few days:

On intake history and physical exam find large firm, mobile cyst-like protrusion under the skin of the dorsal aspect of el pene and the patient tells me, “es un mármol. Para las mujeres.” I wonder if that procedure is covered by insurance.

Photokeratitis vs. the ocular manifestations of the great masquerader, syphilis. I was like, really?

Due to a scheduling error, completing a sleep apnea work up on the wrong patient, in Spanish. Turns out that when you simply answer “sí” to every question, as my patient did, I could diagnose you with paroxysmal nocturnal dyspnea, when all you needed was your GERD meds renewed.

Frothy urine.

Hemochromatosis (diagnosed through trans-oceanic collaboration with the most famous PA-S in Norwegian-Hawaiian history)

Epididymitis vs. Spermatocele. I never thought I would actually perform the physical exam test known as transillumination of the scrotum. How wrong I was.

Time in prison is dwindling down. Scratch marks are approaching thirty.

Before Lunch

2009-07-20T18:24:00.000-07:00

Long week of "chronic care" patients. Nothing exciting enough to jump up and down about. Nothing funny enough to laugh out loud about. Nothing depressing enough to vent about. Just a long week of HIV, Hep C, DM, HTN, chronic pain, and hypothyroidism. OK maybe a bit of subconscious venting there....

I went with the doctor to the special housing unit where patients are on lock down 22 hours a day, and can walk back and forth in a little kennel like structure for the other 2 hours. We practiced medicine in what seemed like a dusty closet. A musty concrete smell clouded the body odor. I could hear the showers down the hall from where I was seeing patients. The whole building echoed loudly with the sounds of guards and radios and showers. The orange of the inmates jumpsuit was a sharp contrast to the gray and white metal of the cells, the floors, and the handcuffs they wore throughout the exam.

Awareness of surroundings is critical in this environment. But this heightened attention creates a shifting of senses. The mindfulness leads to a sharpness. The background becomes just as important as what as in front of you. The ink scratch.. of the tattoo.. on the arm.. of the patient.. in the jumpsuit..on the table.. in the jail cell..with a window..to the outside..with it's blue sky....all individual pieces that make up the terrain that my senses navigate.

Then I went to lunch.

2009-07-14T19:50:00.000-07:00

No sign of Bernie today, I guess they sent him to another FCI in North Carolina.
Release date: year 2139.

Had 3 patients today that were being released within the next 2 months. Through similar grins, each told me the exact number of days they had left.

27 yo with recent diagnosis of HIV will get out without an opportunistic infection, but with a rapidly dropping CD4 count.

44 yo with chronic Hepatits C will get out with only half the anti-viral treatment he needs. I doubt he is willing to stay for the remainder. I also doubt he will complete the treatment in Mexico, where this gringo plans on heading after his halfway house stay.

71 yo with hypertension, hyperlipidemia, and "a 50 year old wife waiting for me on the outside." His blood pressure is the last thing on his list of things to take care of when he heads to Portland in 23 days.

I/M

2009-07-13T16:05:00.000-07:00

Most SOAP notes start with: 55 yo gentleman.... or 40 yo female....19 yo patient....or 23 yo man....a way to convey an image in the reader's mind, a quick identity for the patient. Sometimes other descriptors are added to enhance the image: well-appearing....pleasant.....morbidly obese.....Hispanic......Caucasian......you name it.

In prison, the doctors simply write I/M .

Inmate. That is what they are. That is the only image that they wish to convey and the only identity that they permit them to have.

I refuse and still write "patient" (gender is assumed in an all-male facility). A subtle difference, perhaps. Maybe just a shortcut they use to save a few key strokes. Or with the first word of the entire assessment, are they are setting the tone early? Maybe with three key strokes: I/M buys them the excuse they were looking for. The excuse to blow off a nagging symptom, to refuse a CT scan, to withhold a new medication. Maybe it is a reminder to them, the first thing they and future readers will see when they open the chart: Inmate, Inmate, Inmate.

I can't be sure. But for now, I'm writing "patient" not I/M, because it feels like that's why I am here. To help a patient. To not harm a patient. To listen to a patient.

(((((((My next post could easily be a rant about how I think it is absurd that the 50 million people without health insurance (and without a prison sentence) don't have anywhere close to the access to health care that these inmates, er, patients have. So before you label me a complete Hug-a-Thug, know that I am conflicted to say the least.)))))))))))

Black Hairy Tongue

2009-07-10T17:18:00.000-07:00



	Apparently most people take a photo when they get Black Hairy Tongue.
	Judging by the hundreds available on Google Images. My patient lives in prison, where they don't have cameras. At least not the point-n-shoot type Plenty of surveillance cameras. None of which caught my guy's intermittent symptoms Better luck next time.

The Jovial Jailer and a Pair of Undies

2009-07-07T20:24:00.001-07:00

First time to the "jail" today, which is where they house inmates who have not been sentenced, or are waiting to be transferred elsewhere. The "elsewhere" could be anywhere from the "camp" down the road (think Club Fed) or a maximum security prison (think Not Good).

While the duties of the PA at the Jail are minimal and the learning opportunities scarce, it was good to see a different side of the facility. The prison clinic, where we were last week is akin to any clinic. Inmates come to us. They sit in a waiting room until we call them in. We treat them (or don't) and then they leave, wander off back to their "cellie" (cell mate) and go about their life in prison.

In the Jail, we go to them. First thing in the morning, the PA drags me around to different cells to hand out medication, check blood sugars, and administer insulin to those who require it. We wake some up and they scramble out of bed in their boxer shorts, to come to the giant metal door that we have just swung open. Others are already up, pacing in their cell. 22 hours of lockdown per day, translates to precious minutes outside the tiny cell, on the basketball court, or shopping in the commissary.

The PA is a large, jovial man who laughs with the inmates, remembering little tidbits about each one. He acts like a tour guide, happily pointing out things of interest, maybe hyping things up a little bit to give an edge of excitement. His sense of humor evaporates when a Body Alarm goes off over his radio. The Body Alarm is a staff members lifeline and they wear it on their belt. Pushing it when in danger triggers an immediate and very serious swarm of staff. For about 60 seconds, things got very chaotic. When it went off, we were out in the jail, outnumbered by blue jumpsuits about 40 to 2. The once jolly PA just starts running. Guards are yelling, the PA is yelling, we are all running towards the door. I pause for a second, not knowing if we were running away from trouble or towards trouble. I contemplate the consequence of both. If I am supposed to be running toward trouble, at least I have lots of "my kind" that will be there. If I am supposed to be running away from trouble then I.....then why am I pausing to contemplate this? Keep running!

About 7 of us are crammed up next to the giant steel exit door yelling for it to open. When it opens with a buzz, we rush through it and slam it behind us. It is at this point that we hear "False Alarm" over the radio. And everybody takes a deep breath. I learn that, in fact we were running toward trouble. That's what you do I guess. I knew the anti-climatic False Alarm would be a disappointment to my blog readers (except my mother), so I apologize for that and will end this post on a different note.

We were supposed to do a full History and Physical exam on a man who disrupted a commercial flight, forcing it to make an emergency landing, by wearing women's underwear on his head, among other things. He couldn't make the appointment because he was using the Law Library and the PA didn't want to disrupt his Law Library time. I was trying to figure out what obscure statute he was referencing that pertained to his innocence. Are there legal precedents set for this? Is he planning an appeal that will change the face of improper underwear-wearing flight disruption convictions? I just pictured him perusing the aisles of the Law Library, maybe taking a book back to his desk with one of those little green Law Library lamps on it, all the while with a pair of pink underwear on his head, just knowing that he is going to find that nugget of legal information that will set him free one day.

In the background....

2009-07-03T22:26:00.000-07:00

After the intense background investigation paperwork that was completed months in advance, which included accounting for an address and place of work for every single day of every single month for the last 7 years, and providing a name and address of somebody who could verify that you lived at address X and providing yet another person who could verify that you worked at job Y, and creating a mountain of paperwork for somebody that has had a lot of jobs and a lot of addresses and also creating frustration for somebody who is not a big fan of run-on sentences who is now forced to write a very long one, as this is the only proper way to describe such a thorough background check that in the end....DIDN'T GET DONE.

So after a week, I don't have computer access. And the warden looks like he wants to fight me. And he looks like Chuck Norris, except he has this big Oval Office overlooking the prison grounds and he is in charge of fighting anybody that doesn't have their background check completed.

But they still let me use liquid nitrogen to freeze warts off another man's penis. Which is nice of them. I guess they assume that nothing in the unfinished background check will create an urgent need to prohibit me from such enlightening clinical activity.

Long weekend for this Govvy Employee!

2009-06-30T17:24:00.000-07:00

The nurses rocked in the ER. I'm glad I eventually bought them all junk food and strawberries as a way of saying thanks. I never took vitals. I ACE wrapped only when I wanted to. Suture trays were set up for me in advance. I gave one shot in 6 weeks. They collected and cleaned up urine and spilled urine...it was plush. It was such a well-oiled machine that for me to disrupt the system by trying to help out, would create an inefficiency. And, I was busy doing other important things, I rationalize, like diagnosing Lower Back Pain Not Otherwise Specified.

In the prison, I will be the triage nurse, medical assistant, charge nurse, clerk, and PA student. In addition to the history, physical and charting we'll be doing all the vitals, medications, scheduling of patients, transporting of patients to rooms, EKGs....I might put in a few hours at the cafeteria making mashed potatoes so I can round out my curriculum vitae.

I am pretty excited about this diversification of duties, actually. Lots of procedures to be done here, like toenail removals and cryotherapy. I had a 30 second patient encounter today that involved simply having the patient stick his arm through the small latched window from the suicidal isolation room so I could inject his deltoid with some medicine. It felt a little funny. No introductions, no eye contact. Just grab that deltoid, poke it, and walk away.

Great to be home in sunny Portland with the wife and puppy. I hope this 6 weeks goes by nice and slow!

Prison Medicine Day One

2009-06-29T16:13:00.000-07:00

This is going to be interesting.

In some ways, there will be a lot for me learn, coming "from the street". Like how to unlock and lock every door you go through all day.

In other ways, it will be more of the same. For example, a pus-filled abscess in prison looks just like a pus-filled abscess on Whidbey Island. Patients hurt and they don't want to.

It's a lot quieter in prison, though. Everybody is very calm so far. We'll see how long that lasts.

Clean & Free

2009-06-25T10:45:00.000-07:00

Closing in on the end. With 2 days off before my last 2 shifts and feeling a bit of island fever, I had to get to the mainland. I don't really like being surrounded by water, unless I can be immersed in the liquid, not just look at it.

So I went to Forks, WA. Fellow PA-S and blogger is rotating there, and assured me that there would be room on the floor for me to sleep. Outside of town, at the end of the road, is La Push, Home of the Quilete Indians and a consistent wave (and rain and cold and supposedly lots of sharks).

Tuesday afternoon conditions were nice. Calm, glassy, small waves. As I paddled out, 3 guys got out and left. Solo session in an unknown locale.

After a few hours, I drove into town to watch JW play softball. He is playing for "Clean and Free" a local AA team. (No, not AA, like "double A" farm team). They played well against Subway's team. At one point, JW did a head first slide into second base, exposing both his base running prowess and his "sensitive parts" to the crowd (and the gravelly dirt). Despite the efforts, they lost (by a lot). Suprisingly, Jake was the only one wearing a Clean & Free jersey in the bar afterwards where we shared a pitcher of beer.

Wednesday early morning session at La Push was rainy and cold, but provided fun waves. And again, solo. After an hour or so, another surfer paddled out. He said he was suprised to see me out here alone, and that he would never paddle out solo. And while, as a professional courtesy, the name of the specific fish goes unmentioned while our legs dangle below our surfboards, it is assumed that the reason that people don't come out here alone is that......they actually aren't alone. Many "landlords" occupy this area. A sea lion pokes his head out of the water and stares at me from about 20 feet away. A few fish jump here and there. The other surfer catches a wave to the beach and walks back to his car. The rain pounds on my wetsuit. My legs dangle in the dark water. My heart beats. The sea lion poke his head back up, curious to see what I am going to do. I catch the next wave in. I was ready to get out anyway, I tell myself.

Numbness

2009-06-23T11:20:00.000-07:00

Hotel Suite Scene "Dirty Rotten Scoundrels" - Watch the best video clips here

Numbness.
Everybody is numb, if you ask. Bursitis? Numb. Ankle sprain? Totally numb. Strep throat? If I asked, they would say numb. Just like everybody that feels sick, when asked will say, "Yes, I've had chills", every injured person says "Yes, I have numbness." Numb, numb, numb. It doesn't mean anything, if everybody is numb.

Bug Bites and Paragliders

2009-06-22T11:13:00.000-07:00

There are 2 young docs in the ER that perpetually seem flustered. When it is busy, they spend more time grumbling then working. They sit in front of the computer and shuffle through the patients they have yet to see, like they are shuffling their poker hand around to see if they can make a straight out of nothing. The hand they were dealt was a full house, but that is a losing hand unless you can empty it.

I show up at noon yesterday and start picking up patients. Young Doc is rushing about tending to a new CVA and a hypotensive patient with positve FAST exam. She says in a slightly condescending manner, "I'll see the sick patients and when I'm done you can tell me about bug bites." I skip the bug bites in room 13, and go straight for the diarrhea in room 9 as a subtle stand against PA pigeon holing. I figured the diarrhea had a bigger, albeit stickier, work up and a more complicated differential, so when young doc was done saving lives she could see the bug bites.

The only lesson from the diarrhea experience was one I have known for years: avoid the Jack in the Box chain. Something is just not right with that place.

Later in the evening, with the Young Doc phasing out and the Old Doc taking command, we found a rhythm in the busy hive that is the ER. Old Doc understands that I my job here is not to see just "Fast Track" patients and support the doctors as they see the "criticals". If they want to hire a PA to do that, fine. As a student, we see whoever. Including Paragliding accidents.

57 yo handle bar mustachioed paraglider stalled 15 feet above his landing and dropped flat on his back onto rocks, with a bounce. +Loss of conciousness, complaining of back pain, epistaxis. Attributes the fact that he doesn't know the month, date, or what he had for breakfast to "I'm and Artist." Friends dragged him off the beach and drove him to the ER. Actually, If they had called 911, there would have been other people in the room besides me and the nurse. But they didn't and I was in charge.

CT head, c-spine, t-spine, chest x-ray.....long story short he had a burst fracture of T4, which was a fortunate diagnosis for the mechanism of injury. He walked out with a boatload of pain meds (and stool softeners).

I have no problem seeing the simple stuff. It feels good, in fact, to bounce from room to room and feel like you have a grasp on what is going on. But because I am paying to work here, not vice versa, I'll take the liberty to see the bug bites and the paragliders.

BONUS QUIZ: What medication did I prescribe for the paraglider that will be administered intra-nasally? First person to comment with the right answer wins a prize!

More Baseball Medicine Talk

2009-06-20T11:13:00.000-07:00

I should retire right now while batting 1.000 with ABGs.
Respiratory therapist missed twice, so my preceptor said "Let's let the PA student try".
I've stuck lots of veins. Jabbing a needle into somebody's radial artery has a different feel.
Straight in. Helps when the patient is comatose.
One for One. This high batting average will not last. Unless I refuse to step up to the plate again.

Mirror Image

2009-06-17T12:14:00.001-07:00

Room 13: 15 yo male, lip laceration.
Sign me up. This is not like a high rise hotel that skips from floor 12 to 14 to avoid the unluckiest number. We are proud of our room 13. Being in the "Fast Track" area, it tends to get the unlucky patients that did unlucky things like "stepped on a nail" or "slipped on a boat". Not quite enough to get you into the trauma bay but enough to get you into Old 13. This happens to be where most of my suturing has taken place, so if you consider having a young PA student who believes in Trial & Error learning, pass needle and thread through your wound to be unlucky then it's the perfect room for you.

As soon as I made eye contact with the 15 year old, I knew I recognized him. He was me, about 17 years ago. He looked like me. He talked like me. OK, well he didn't talk like me, because his upper lip was swollen to the size of an orange slice and curled upward to the ceiling in a strange way. When he told me about the baseball he took to the face, I instantly was taken back to when I was hit by the ball. The stunned, starry, buzzing face that comes from only a hardball to the face is a feeling that isn't easily forgotten. Your ears ring. The temperature rises 10 degrees. The other kids look at you funny. The blood trickling onto your shirt....

When he told me it was a grounder, a bad hop, I knew that he also played second base, like I did. Although I never had stitches for any baseball related trauma, I felt this guy's pain, more so than any boating injury, birdfeeder mishap, or bronchitis so far. I was there with him, taking bad hops, bad throws, bad pitches. I felt the sting.

After deciding that the laceration did not cross the vermillion border, and thus not a plastic surgery case, I placed 8 stitches in his upper lip. I denied his mother's request to incorporate the lower lip into this set of sutures, despite her insistence that it would make for a quieter summer.

His summer is starting with a fat lip, but summer break when you are 15 cannot be ruined by such a minor insult. He has plans. He asked me if he could work tomorrow, and when he said he was a bagger/stockboy at the local grocery store, I almost laughed out loud. Again, almost two decades ago there I am: Bagging groceries at my local store, playing baseball, getting smacked in the face. All day we run around crossing paths with hundreds of people. Once in a while, one of them has the ability to take us back to the same burning pain we've experienced, as well as the same youthful joy that we've relished in.

Clinical Equations

2009-06-16T14:05:00.000-07:00

Dog's Paw + Child's Foot + Jump = Puncture Wound + Antibiotics + Animal Control

Slippery Ladder + Bucket of Wood Stain/Pain Thinner + Open Mouth = Belly Pain

Semen + Blood = Anxiety

Garage Door + Head = Disorientation

Third Story Window + Broken Screen + 12 yo Girl + Gravity = Stick Impaled in Arm Only!

House, MD Watching x (dizzy,syncope,abdominal pain,toothache,finger twitching) = Strange Jungle Disease, according to patient

12 oz can of Mountain Dew x 12 per day = Renal Pelvocaliectasis = My Kidneys Hate Me.

Child + Tylenol Bottle as Toy + Mom taking Nap = Red stains on mouth, shirt, carpet + Several Hours in Emergency Room

A few recent pics:

2009-06-11T20:11:00.000-07:00

Woke up this morning with enough wind that I thought maybe, just maybe there’d be some junky but surfable waves at Fort Ebey. With this wishful thinking,a surf check is born. Things needed for a proper morning surf check include:

•Coffee (The lady at Miriam’s in Coupeville starts making my Americano when I walk in the door.)
•Your surfboard in case it looks like Waikiki.
•A plan for what to do when it looks like Lake Erie.

Flat. Flatter than Lake Erie. My backup plan is set into motion: Drive to Cananda. Multiple motives exist for this trip:

•The other day, while assessing a patient’s mental status, I asked, among other things, for the name of the President. He said, “well, I am from Canada, so that’s not a fair question.” Granted, this man didn’t know his own address or what month it was so I could’ve stopped right there. But because the request of naming government leaders was already out there, I only thought it fair to reword with a more Canadian friendly question. Who’s the Prime Minister of Canada, then? As soon as I asked it, I realized I didn’t know the answer to my own question. How alert and oriented does that make me? He said something like Stephen Harper, and to me that sounded more like a basketball player, so I considered him delusional and had him admitted. I decided then and there that I needed to go North for a visit.

•I am a _____ and driving somewhere just to drive there, never sounds like a bad idea. My surname actually translates to Of the Rose, which is a nod to the compass rose that has been utilized throughout my bloodline.

•In a future rotation I will be within driving distance of Old Mexico, and the more International I can make these rotations seem, the better it will look on my résumé.

•I hadn’t been treated like a terrorist in a while, so I was due for good border crossing.

A piece of advice for anybody going to the big C, eh? N, eh? D, eh? is to actually look at a map and at least pick out one town to tell the bulletproof vest wearing Canadian Border Cop that that is where you are going. All I really had was “I am here to visit.” He needed specifics and I just froze. It doesn’t help that a surfboard bag and a body bag are very similar in appearance, especially when being brought across international boundaries by an unshaven, unshowered man on Wednesday morning. They took my driver’s license, my passport, my cell phone and my car keys and told me to wait inside. I felt like a vulnerable ER patient, forced to wear nothing but a cheap open-backed gown, and told to sit in a small room and wait to be told your fate.

After a short-lived visit with our northern neighbors, I found out that the US Border Patrol also frowned on me “just taking a quick trip” to Canada. I even rehearsed my statement while in line. But once the questioning began of why exactly I came up here, by myself, on a Wednesday, in a van, for a few short hours….I just couldn’t convince them of my aforementioned motives. Oh, and apparently a surfboard bag looks just as much like a body bag in the southbound lanes as it did to the Canucks guarding the northbound route. Once again, keys, passport, wait inside with the other miscreants. Why are my palms sweating trying to innocently make passage to my own motherland?

Maybe both the Canadian and US Border Patrols have successfully convinced me that, yes that was a stupid thing to do on a Wednesday morning. It’s like they had seen my To Do List…Let’s see, laundry, phone calls, pay that bill, read up on Huntington’s Disease…..look at all this stuff you should be doing, Mr. DuRoss, you don’t deserve to make some willy nilly flight of fancy to another country, with all these other things going on….

I spent more time in Customs than I did in Canada. I didn’t even learn anything about the leader of the Canadian Government. But, I made it back to Whidbey Island without any latex gloves being broken out, so I consider that a small victory. Next time, I’m leaving the body bag at home. Actually, the next time will likely be a Mexican border crossing, so the surfboard will be coming along. I guess next time I just need a better story to go along with it.

More Heard from the Herd

2009-06-09T11:25:00.000-07:00

"I've got an apple stuck in my throat," says the drooling lady.

"I pushed the Walk Button," repeats the pedestrian who doesn't remember being hit by and flipped up and over the sedan.

"I've been in the Navy for 25 years, I know how to tie a square knot," says the unimpressed sailor as he watches me sew his soup can laceration.

"If you can get my potassium to 2.5, I'll be doing calisthenics in the hallway," says the emaciated and weak lady who was admitted last week with a K+ of 1.6 (nl = 3.5-5)

"I called 911 again," says the same lady with a toothache from last week.

"Attackacardia," reads the chief complaint, filled out by our registrar, referring to the patient's rapid heart rate.

"The blackberry bushes were losing for a while," says the frustrated and wounded fighter of the oh-so-tasty yet oh-so overgrowingly annoying berry when his new weapon of choice, gas-powered hedge trimmers, turned against him by opening the skin on his left knee.

Halftime Show

2009-06-09T11:07:00.000-07:00

Diverse stories, not-so diverse ethnicity.

Top 10 Diagnoses
	079.99 - UNSPECIFIED VIRAL INFECTION
	847.2 - SPRAIN/STRAIN LUMBAR REGION
	599.0 - URINARY TRACT INFECTION UNSPEC
	786.50 - UNSPEC CHEST PAIN

	682.2 - CELLULITIS/ABSCESS TRUNK
	292.0 - DRUG WITHDRAWAL
	461.9 - UNS ACUTE SINUSITIS
	466.0 - ACUTE BRONCHITIS
	682.6 - CELLULITIS/ABSCESS LEG EX FOOT
	780.2 - SYNCOPE AND COLLAPSE

Despite such diverse stories, it still often boils down to back pain, viruses, pee pain, drugs, and "bug bites".

high pressure

2009-06-08T11:20:00.001-07:00

Speaking of stories, here's a guy who can spin a yarn:

Me: Was there an initial injury or event that occurred, causing you this low back pain?

Guy: (abbreviated for brevity) You know those water slides? The ones where you go through the tunnel? Well, I used to be a lot fatter than I am now (He's still pretty obese). I was going down the slide and I got wedged in the tube and I was stuck. It was near the bottom of the slide. All this water started building up behind me and the pressure finally built up enough to shoot me through. But it was so much pressure that it shot me through the little pool at the bottom and onto the concrete.

Me: Wow.

Me: Any recent injury to cause this recent worsening of the pain?

Guy: Well, I was bending over to turn off this outdoor faucet....that kinda hurt.....but 2 days ago my new propane tank for my BBQ exploded. I was sent flying into the air and did a corkscrew and landed on my back. (To his credit, his face is red and his eyebrows are scorched off)

Me: Wow.

Guy: You know those big green freeway signs? I used to have to scrap those in California. And I was cutting one down with this big torch and a huge flaming hot ball of steel landed on my chest and I wasn't wearing a shirt, let me show you the scar. (Looks better than a cigarette burn)

Note: This patient has been awarded by my preceptor a Lifetime Achievement Award for Creativity and Originality with the Waterslide Story, that he had also heard a few months ago.
Th prize for this prestigious award includes a no-questions-asked Percocet upon arrival to the ER, and a free IM shot of Dilaudid with Phenergan before you leave. Quite an honor!

2009-06-07T11:08:00.000-07:00

From the parking lot of the closed public library, where I just finished entering Typhon patients from yesterday. There are just so many stories here. I don't have to try very hard. It's just a constant flow from one room to the next, walking out of one wild history into the next heartbreaking tale. It'd be impossible to make this stuff up.

29 yo F on the island for great grandmas birthday party decides to go on a Meth, alcohol, and prescription narcotic binge for 4 days. Disappears from family. Re-injures her already broken and casted foot sometime during the bender.

24 yo M in Seattle came down to parking garage to see his wife being attacked from behind. He runs up and punches the guy in the back of the head once, causing the assailant to run, but also his fifth metatarsal to break. Bad enough for surgery. I truly believed this story, although I may sound gullible. Maybe he just was drunk and punched a wall, felt silly and made up a hero story.

85 yo M Nausea/Vomiting........troponin = 97.54! Classic huge heart attack with no chest pain, no SOB, no nothing. Highest troponin that any of the docs had seen.

61 yo F Nausea/Vomiting after drinking 1 too many margaritas....develops headache and dizzyness whiles discharge instructions are being written. Head CT = Huge head bleed = Helicopter to Seattle.

No real theme last night other than it seemed like a good night to stay on ones toes.

The Awristocrats of Whidbey Island

2009-06-05T16:24:00.000-07:00

After some jet setting down to Portland and thoroughly enjoying my mainland time, it was back to the island for me. Left the big city at 6am, battled Sea-Tac traffic squirming in my sweaty leather seat of my no AC-working Mazda as the blazing sun was reminding me that a Noon O'clock start in the ER was going to be a push. A ferry ride full of Euros later, I made it to the ER w/ 3 minutes to spare.

Apparently, a thunder storm hit Portland when I left. But I entered my own storm, of a nature previously not witnessed. It was the Great Wrist Storm of 2009. While brief, it was intense, and in a matter of 2 hours, we were in a deluge of displaced carpals, distal ulnas, and comminuted radii. We had 8 wrist injuries in this time. That is a lot for a 13 bed ER on an island of only 10,000 wrists. (and remember all except the saltiest of sailors up here, have two each)

11 yo boy fell skatebording
9 yo boy fell walking backwards
72 yo lady fell while slipping on a rock
10 yo boy tackled at school
19 yo girl wrist vs. knife in a brownie pan incident
17 yo guy boxer's fracture
44 yo I don't even know what happened to her (I can only keep up for so long)
18 yo wrist vs brick (that happened to be on the ground which happened to be adjacent to a trampoline which happens to be bouncy and happens to toss children and adults off with very little discrimination)

When I walked into the Fast Track area, there was a guy on the left with a right wrist injury and a guy on the right with a left wrist injury. I was hearing words like Monteggia and Galeazzi being thrown around. I heard at least 4 providers provide mnemonics for remembering the carpal bones. When the clouds cleared and last wrist was discharged, we surveyed the damage: We ran out of air splints. We're down to the 8 inch ACE wraps. Ortho is still on hold for that one guy. But we never ran out of Vicodin. No, we will never run out of Vicodin.

Library is closing. I went to an Ultrasound training session today, so almost normal hours for me. Now they are kicking me out, so gotta run back into the Internetless world. Miss you all!

Heard from the Herd

2009-06-02T12:45:00.000-07:00

"I punched a chandelier," says the meth smoker.

"It hurts so bad that when I dropped a banana on it, I screamed. Then when I dropped a cassette tape on it, I screamed again," says the lady who fell off a ladder.

"I am Paul, what's your name?" asks the 50 y.o. man that didn't remember me coming into his room 5 minutes ago, let alone what year it is, who the President is, or what he had for breakfast. (New symptom today, no trauma, no drugs, no head bleed after CT)

"I got a bug bite," says almost everybody with MRSA.

"I got MRSA," says everybody who has a bug bite.

"Your next pizza is on me," says the pizzerria owner after I sew his finger.

"I called 911," says the lady with tooth pain.

"It's healing up well," says the toothless son of a 160 pack year history (4 ppd x 40 years) smoker who fell asleep on the couch with a ciggie in his mouth, as he (the son) rubs the oozing wound with his bare finger. "We came in because he's constipated."

"It's not erysipelas," says the hospitalist to the PA student who thought he was pretty cool for diagnosing erysipelas in the ER, thus crushing the 4 minutes of fame and glory that he had been basking in before the hospitalist came in.

"I hate chandeliers," declares the meth smoker, clarifying exactly why he punched it.

The Lamest ER Visit Thus Far

2009-06-01T11:10:00.000-07:00

I've got a rash.
Where is it?
Right there on my foot.
That? (3-4 red dots on dorsal aspect of right foot...initial impression: not very impressive contact dermatitis vs. even less impressive poison ivy)
Yes.
How?
I don't know.
Been seen?
Yes, I have Benadryl, Hydrocortisone cream, and prednisone from my doctor.
Is it working?
Yes.
OK.
I might need to be off work so I can air it out and I work around electricity and if I don't have a boot on my right foot then I am not grounded and......I might just explode spontaneously....
I see. Goodbye.
I was not this curt. But I wanted to be. This guy is a Navy man. Active Duty. Defending our country. I think there are some vets out there that would like to kick this guy in the mouth with their gangrenous trench foot to give him something real to complain about. Wow.

Can you tell the honeymoon is over?
A little tired of the "Stay Late-Look Great - Rah Rah Rah" thing. I am scheduled an hour earlier than the "middle doc". I get run ragged by the day shift. They leave, and the night shift comes in fresh. I stay later than the "middle doc". Just enough time to sleep and enter Typhon data before work again. I am actually enjoying it immensely, and don't mean to moan about a few extra hours. But when your foot itches, and is getting much better with the 3 medicines you have been taking, and you drive up to the hospital with a big red EMERGENCY sign.....just remember that there might be somebody inside that has worked five 13 hour days and will still be professional and empathetic but only because they have to be.

2009-05-31T11:34:00.000-07:00

We eventually make people happy in the ER. They come in hurting. They wait around until they are hurting and frustrated. Then we poke and prod at them so they are hurting, frustrated and bleeding. Then we give them Percocet and they leave stoned and smiling, thanking you for all your hard work. Another satisfied customer, ready to spread the word of the great care they received at Whidbey General.

(Graph is from Typhon and shows my prescribing trend in the last 9 days.)

The Top 3 Reasons Why The ER Nurses Hate Me

2009-05-30T10:26:00.000-07:00

1. I still haven't brought donuts (insert derogatory comment about them needing more celery sticks and less donuts)

2. I haven't gotten kicked in the face by a psych patient yet, which when it did happen to a previous student was apparently quite entertaining to the nursing staff, and furthermore has set the standard pretty darn high for future students (and future psych patients).

3. I ordered 4 enemas last night. I think there is a salad shortage on the island. Things got messy. I click a button to order it and they put the face shields on and head into the trenches, not happy.

2009-05-29T11:19:00.000-07:00

Started my shift yesterday with a 66 yo with no previous history of anything in cardiac arrest. CPR, shock and epi on scene, now he has a perfusable rhythm and a BP of 220/112.

Ended the shift with a felon. Doc lanced it, I only watched. next one is mine.

Today's theme: Prison, which is where I am headed next. Just emailed them. Still seems like a long way off. For a preview check out www.dontjust.blogspot.com

2009-05-27T18:54:00.001-07:00

Saw a 12-ft fall from tree, and a dog bite. Apparently on Whidbey, the falls and the bites can get a lot worse. I will be waiting with my Morphine and Sea Lion Anti-Venom at the ready.

2009-05-27T18:47:00.000-07:00

Click to make the Whidbey Island Wonders bigger!

Intros

2009-05-25T10:50:00.000-07:00

You walk in to the room and introduce yourself as the Physician Assistant Student. How do you enunciate and emphasize these three words?

a)physician assistant student…they think you are speaking a foreign language, you must emphasize something!
b)PHYSICIAN assistant student…they think you are the doctor
c)physician ASSISTANT student…they think you are the MA or nurse or clerk
d)physician assistant STUDENT…they tell you their neighbor’s son also went to Med School and..
e)PHYSICIAN…ASSISTANT…STUDENT…..they are offended that you think they are deaf & dumb

Answer: I have been going for option d) as it highlights the most important word and lowers the patient expectations to a level that I can hopefully meet or even exceed.

You reap what you sew

2009-05-24T10:54:00.000-07:00

Sewed up my first patient today.
All week we couldn’t buy a good Newbie PA-S laceration.
“Oh this guy bit his cheek and he’s on Coumadin and the lac is about halfway down his throat…”
“Oh now this one is on a 23 month old kiddo and mom and dad are freaking out”
“Oh this one is on the finger of a old OR nurse who got fired from here and has anger issues and she’s been telling everybody how looooong she’s been waiting (1hr30min) and she’s mad and she wants an ortho consult and she…..”
“And this one….”

I wondered if I was going to have to go down to the Coupeville Butcher, buy a pig’s foot, put a gown on it, slather it up with some Hibiclens, slap it down on an exam table and start sewing to get my fix. But no, I was just waiting for the right patient to arrive. And arrive that patient did, tonight. No, not a 23 year old macho guy. No, not a scruffy red-nosed fella too drunk to know he’s not still at the bar. No, not even a 17 year old who thinks a scar is like a ticket stub proving you paid your way into manhood. My perfect patient for my first sew job? 10 year old girl. Talking about ponies the whole time. And kitties. Bravest patient of the night. Inquisitive, but trusting. Scared, but not whiny. Dad in the room with calming words but a look on his face that told me he wasn’t coming anywhere near the bed, the needles, or his daughter.

From the moment she dropped the sharp garden shears and they plunged into her calf, I think she knew she was getting stitches. What she didn’t know was that she would have a skaky, sweaty, nervous PA student put them in.

I write this from bed with a celebratory beer on my left and Henri, the big black dog on my right.

Learning Curve

2009-05-23T10:39:00.000-07:00

Entering two days worth of data into Typhon before I go to work in an hour has stolen time from creative writing so here's a couple quick things I learned over the last 2 days:

If your wife is choking down a big horse pill and you give her the heimlich, you will still have to come to ER to treat the broken ribs.

If your mother is nice enough to give you her kidney, DO take the meds they tell you to, and DON'T take the kind they sell on the street, if you want to keep your mother's kidney working.

If the PA student before you brought the nurse's donuts you will not make friends with said nurse's until you also bring donuts to said nurses.

A 2 year old can be easily restrained with a properly used pillow case.

If your furniture store is having a Memorial Day Sale and your employee is out with the dreaded H1N1 flu, do not attempt to move 300 lb furniture all by your lonesome.

Gotta go learn some more...bound to get a little nutty w/ the holiday "island" crowd.

2009-05-21T09:24:00.000-07:00

My weekend came early, so I’ve been playing tourist. The owner of this house spends Tuesday through Thursday in Seattle & Bainbridge Island, so the place is all mine. From where I sit and type this I have an expansive view of Admiralty Bay, the Keystone Ferry Terminal, and the beginnings of the Strait of Juan de Fuca. From here I watch huge cruise ships carry people out to sea and Navy warships sneak around. I watch the Port Townsend Ferry come and go, and the orange wind sock at the marina keeps its steady westerly position. A virtual variety show of unidentified birds fills the prairie in front of the house, but continually pay visit to our deck and birdfeeders. Deer lay around the backyard under the shade of an apple tree and watch the rabbits poke around the grass. I can’t make this stuff up! Even the house is like a shrine to nature. I am surrounded by what we call Natural Wonders. Driftwood, shells, rounded glass, buoys, old bottles, feathers, rusted scrap metal, skulls, rocks and dried leaves are intertwined into this living space of furniture, artwork, plants and appliances, with the artistic eye of a museum curator, the naturalist eye of a park ranger, and the beachcomber eye of somebody who has spent decades strolling the shores of Whidbey Island.

And what did I see underneath the Hawthorne Bridge in downtown Portland that one might think I would see here on the Island? If you guessed Sea Lion, you’d be right. Apparently they make 3-4 day hunting trips (some from as far away as San Francisco) for the spring runs of several fresh water fish. We were fortunate to see one surface as we rode our bikes over this city bridge last week.

I swear I am studying medicine, not wildlife biology. While it’s been fun being a beachcomber, hiker, birdwatcher, and coffee shop dweller for the last few days, I am ready to get back to the hospital and be a PA student again.

2009-05-19T13:48:00.001-07:00

2009-05-19T13:41:00.000-07:00

From: 1:32, Tuesday, May 19th
It’s after 1am and I am wired from my first ED shift, so before I sleep it off, let me unload: First, not much sleep last night (nerves + sore throat + chills). Second, early morning to get to the hospital for HR paperwork, etc. Third, as my shift starts one of the docs says to me: I’ve never started a shift this busy. My preceptor comes an hour later and we hit the ground running. 22 patients:
Vertigo
N/V/D x 2
Can’t swallow after tonsillectomy
Syncope
Snowblindness
Back pain x 2
Cellulitis x 2
Chest Pain x 2
Humerus Fracture
Toe vs. Soccer Ball
Dystonic Drug Reaction
IBS x 2
Pneumonia in Lung Cancer Pt
Viral Syndrome x 2
Hypertension and swelling
DVT
The youngest was 4 months and the oldest was 88 years.
I got my first pimping an hour into it. “What kills patients with aortic dissection?” I got it wrong, incorrectly guessing that it ruptures and the patient exsanguinates. He knew the answer, because just the shift before he had cracked some dude’s chest in the middle of the ER and released the pericardial tamponade. He was the talk of the town and the buzz was still palpable in the ER. It was a fair question.
I won’t typically bore you with a list of patient diagnoses in future posts. But I thought this would give you an idea of what I may see in the ER. Plus, without the camera cable I have no pictures yet. Thus, I am working on the 1000 words necessary to match what could have been uploaded in a few seconds.
I am off the next two days. Goals are 1: kick this cold (only had one during didactic year, hoping this is my one for clinical year). 2: review some things like ortho that I have forgotten all about. 3: Explore WI. 4: Resist the temptation to go snowmobiling, run out of gas, get left by friends high in the mountains without goggles or sunglasses and burn my corneas.

'Twas the night before....

2009-05-17T20:07:00.001-07:00

Made it to Whidbey today. Time 4 hours 20 minutes, slightly longer than the 3 hours I had been telling myself. Got stopped by a draw bridge heading out of town, but made up some time by pulling into the ferry dock just as the ferry was pulling up. Tammy's house is beautiful, expansive view of the snow-capped Coast Range, the sound with cruise ships, sailboats, and ferries coming and going, and an abundance of birds, gardens, art and comfort. I can't wait for Audrey to come visit, as it will feel like a little island vacation for us.

Right now sitting in the parking lot of the local (and closed) coffee shop that must have some wifi. Downside to my digs: No Internet. I may have to blog via MicroSoft Word, then make a stop by this coffee joint to upload. Oh and so far the only thing I have forgotten from PDX is my camera to computer cable. Upside: I didn't forget my stethoscope. Downside: You will have to wait a week or so to see the crazy pics this place has to offer. Here is one lifted from the web that feels the closest to what I saw today. Cheers-CD

From Sitting to Running

2009-05-14T21:02:00.000-07:00

Tomorrow is the last day of clinical seminar week, thus concluding our didactic year of PA school (didactic can be loosely translated to the act of sitting on one's duff, being annihilated by 238 slide PowerPoint presentations, then going home to read obscure medical texts until you wake up in a pool of drool). In summary of this year, I feel like I have learned a ton, met some great people, and pushed myself to do things I thought previously impossible.

The true clinical year starts on Monday morning when I report for duty at the Emergency Department on Whidbey Island. This will be the start of 15 months of a whole different story. I expect no sitting, and no PowerPoints.

I have recently found out several new rotations on my schedule. Listed on the right of this blog, you will find the dates and locations. They have been left generic for a reason. Places, names, and specific information will be left general, generic, and at times completely made up . HIPAA (privacy laws) as well as common sense dictate this. I would like to be candid about how my rotations are going so that the reader gets a feel for how life on rotations actually is. If I listed doctor's names or specific clinic names I would put my anonymity in jeopardy. You can help by not using any known/specific names in of your comments.

So here is a quick rundown of my newly scheduled rotations:
#4 in La Jolla, CA....hopefully a mix of surfing, spanish, and internal medicine, not likely in that order. The hospital is a few miles from this point.

#6-#7 in Hood River, OR.....I will likely be living in Portland for this one, making the wintertime commute through the Columbia River Gorge each day. Will be worth every mile to sleep in my own bed, while still having a great rotation in a cool town that has been on our list of "potentials" for a while.

#8 in Portland doing my clinical project. This will be a nice reprieve. I picture myself hanging out in a coffee shop drinking espresso and surfing the InterVebb. It may actually be more work than that.

#9 Trauma. 12 hours+ a day x 6 days, switching between day shift and night shift. As this rotation is in Portland, I will technically be sleeping at home, but essentially living at the hospital.

#10 Ecuador. Can't Wait.

Disclaimer: Any and All of these rotations can and will change, at a moments notice. The more I get excited about any particular city, clinic, afterwork activity, or housing situation the more likely it is to change.

Stay tuned....thanks for reading, thanks for your support!!

Happy Birthday

2009-04-13T18:17:00.000-07:00

First, some updates: Landed some housing on Whidbey Island with a really nice sounding lady. I guess her place is within sight of the ferry. It is a few minutes from the hospital, and a few more minutes to the surf break which apparently can be really fun with a good swell. We were allowed to contact our preceptors today about schedule, attire, etc. etc. so I should be finding out more about this rotation in a few days.

Second, a little taste of my surgery rotation was allowed today, as another student and I were able to observe two C-sections and assist the nurses with cleaning the baby, suctioning, taking the first set of vitals, doing an APGAR score, testing reflexes, and so on. It was amazing to watch both of these births from just a few feet away and it was certainly a well-rehearsed dance between the anesthesiologist, the 2 surgeons, the scrub nurse, and the "baby" nurse. After the initial assessment in the OR, we followed the baby to the nursery where a more thourough exam was completed. After the second C-section we ran back to school with just a minute to spare before our official Surgery Module started.

My brother, my sister-in-law, and my brother-in-law all have April 13th as their birthday. Today I witnessed 2 more people who will share this day as a birthday! What a treat.

Happy Birthday, Chris, Mindy, Gus, Baby X, and Baby Y!!!

Welcome to the Clinical Rotation Blog

2009-03-25T11:13:00.001-07:00

I will be updating this blog throughout my upcoming clinical rotations, as a way to stay connected with friends, family, and other PA students. I hope to post photos, stories, cases, and other random things that I encounter over the next 15 months. I'd love to hear from all of you, so stay in touch, either via the "comments" section, or by email.

Last week, I found out the first three rotations that I will have. Looks like I will get to stay in the Northwest for the summer. You will find my updated Rotation List in the right column. However, because it is exciting to get the first couple rotations assigned, let me expand on them a bit.

Rotation One: Whidbey Island, WA. Follow the Strait of Juan de Fuca inland from the Pacific and you will run right into this island. Depending on how hard you hit, you may end up in the ER there. That's where I will be. 3 1/2 hours from Portland with the ferry ride. This might be one of the rotations that Audrey and Kessler will come visit me, instead of viceversa, as there will be plenty of "islandy" things to do this summer.

Rotation Two: Federal Prison. This will NOT be a rotation that Audrey and Kessler come to visit me. I will commute 1 1/2 hours to the prison from Portland.

Rotation Three: Surgery! In Roseburg, OR. Don't know much about Roseburg. Don't know much about surgery. This is the rotation to find out more about both.

We have just Emergency Medicine and Surgery modules left, after spring break. I am going to attempt a strong finish to the didactic year, and will likely have my head buried in a book for the next month. However, I will update the list and blog as I find out more clinical sites. Thanks for reading!