The bee's knees

So far I have not had a whole lot of positives about my rotations, so I thought I should throw out some of the positive moments. I have to warn that a few of these things may be a little graphic in nature - sorry, that's just the way it is.

1. I've been scrubbing in on TKA's (total knee arthroplasty = joint replacement) why this is cool - I get to where the hood and helmet on top of the whole scrubbing in, gown and gloves. There are about 6 steps to a TKA (way simplified: Knee is suspended and a tourniquet is applied, A vertical incision is made from the upper part of the patella (kneecap) to just below the knee joint, about 4 to 6 inches. Traditional replacements are 8-10 inches, 3. About 1/4 inch is sawed off from the ends of the femur and tibia bones to prepare the surface, The under part of the kneecap is trimmed with a saw and fitted with plastic, The prosthesis is sized, then cemented (and/or) pressed into the bone, The deep tissues are stitched, and the skin is stitched or stapled.) It is a very messy procedure - bone and tissue flying here there everywhere - sometimes chunks land on the face shield of the hood and then slide down like a pickle on a window leaving a lovely smear - this was my experience last Friday. The hood itself is a process, first there's the helmet - thank goodness I ran into a girl PA on another case who gave me the wisest advice about the helmets - take out my pony tail. The helmet have a fan attached to the back to help keep you cool, the battery pack fits in the back pocket of the scrubs (so it's really important that your pants are tied tightly). The hood part slips over the helmet which is placed on by the scrub nurse who helps dress you as you enter the sterile field (and by dressing me I mean gown and gloves). It's really difficult to hear in the hoods - and unlike when wearing just a mask - everyone can see your entire face, so I have to pay special attention not to stand with my mouth open while intently watching. Well that's probably more than enough info about TKAs for now - here's a link to one of the main companies we use for the prosthetics: stryker triathalon http://www.stryker.com/en-us/products/Orthopaedics/KneeReplacement/Primary/Triathlon/index.htm

See the pics at the beginning of the post to see the hoods and pre and post op examples...

2. OR fashion. I know this might seem strange but there are really important things to know about scrubs, shoe covers and caps when selecting the ones you will be wearing all day. In the women's locker room there are two sets of shelves of blue scrubs. One set of tops and one bottoms- this is where is gets tricky. There are mens and womens scrubs, both available from S-XXL. The women's pants are elastic wastebanded and tapered - very tapered and the tops have a lovely modest neckline (not a V) with two pockets on the bottom on each side. The men's bottoms have a drawstring and are more of a relax fit straight leg type of pant. The tops have a V neck (not a plunging neckline, but a definite V) and one pocket on the left breast. Hats: women have cafeteria style blue bouffant caps (same one patients get) but they have regular and large sizes, men have the tie caps, and hats that extend to cover a beard. Shoe covers- an often overlooked necessity. There are the regular show covers - one size fits all and then there are the shoe covers that extend up tot he knee - essential when doing a knee arthroscopy when water is pouring all over the place, seriously it's like lake Huron in there when we're done. If you don't wear these - as I have found (although they never seem to be out of them in the locker room) your entire leg will be wet from water and a little bit of your shoes. May not seem too bad considering it rains all the time here - shoes get wet, no biggie, but then you realize the water came from inside the knee during the procedure.

Oh and here's a link of pics of an actual TKA procedure I found... it's a little gorey, be warned

http://www.genufix.com/total_knee_replacement_photos.htm
And here's a link for you to do a "virtual TKA" : http://www.edheads.org/activities/knee/

3. I got to inject a couple knees today one with Orthovisc and the other with Synvisc. whoohoo!!

Ok, I think that's probably enough for one post about a rotation...

Change is a comin'

4 days of heat and then the cool rain came - typical but a welcome change. So one of my favorite things about our new apartment is our breakfast nook. It's a perfect space for our card table turned dinner table (it works for our space). We had the table in the last apartment but it was a part of the "living room/kitchen/dining" area - so it kind of became a great place for mail and odds and ends. So now in our new nook we actually use it as a table (an occasional place to do the ironing). So all this being said, we have been able actually sit down and have a meal together. It's funny how having a place to just sit and eat changes the conversation and improves communication. How did we go so long with out a table?

Yesterday's clinic was uneventful. More suture and staple removal for me an a whole lot of watching - bummer. On the plus side one of the clinical team professors called me after emailing her my concerns and is making a site visit Thursday which I am really grateful for and they are seriously considering changing up my rotation. It's not that I haven't learned anything, it's just not what I (or the program) think should be happening. This is mostly impart to the fact they lost a provider not to long ago and have a few of those patients lingering in the line up, and on the other hand it's just a gosh darn busy practice with surgeries booked 10 weeks in advance. I just think they are took busy of a clinic for a student. I tried really hard to remain objective when talking to Prof. telling her what I was doing and not doing and left out the part about how I think my preceptor is well let's just say won't be winning the award for preceptor of the year but he does try when he can to teach me something. Then again maybe it's me, maybe I'm not showing him I can handle more responsibility. Point is - change coming soon. Today, I have off, both the doc and PA are out of the office and the other surgeon I was supposed to go with per my doc didn't want to sign a million papers for one day, so I will be catching up on my patient logging and reading - too bad Shawn has a 12lead class today but it's really awesome he has that opportunity.
Side notes: So one really awesome thing about AMR is they have all these free classes for their paramedics to attend as part of their required refresher courses for license renewal - all taught by the medical director. They last 4 hours or so, but if you attend just half of them in a year all your hours are covered for renewal - how great is that??

"And I was running" -Forest Gump

Shawn went back to days today - quite a change from nights and since he switched shifts it just so happens that he will have next weekend off which is awesome considering he had this past weekend off too!! YAY! We enjoyed the early summer weather at the pool swimming and running. Running is sort of our new thing, Shawn runs an easy 5K in 30 min and I'm not too far behind him and he ran some ridiculous amount of miles last week. CRAZY! Cardiovascularly we are in the best shape of our lives which is just an awesome feeling. I would never have started running without him - I love my Shawnee! The only downside of the running craze is whenever I feel a slight pain or creek in my legs - especially my knees - I think, gosh I hope I didn't tear my meniscus, I think I stepped a little crooked. I don't know how many people in clinic I've seen with a torn meniscus from walking, running or just aging. That's the worse part about being in healthcare - you start wondering and worrying and thinking about every little thing that goes one with your body that you wouldn't think anything of normally. I swear it's the fastest way to becoming a hypochondriac.

Clinic today was relatively uneventful. Steady and regular patient flow. I got to do my first pre-surgical H&P (history and physical) but it ended up being the most abbreviated H&P I think I have ever seen, let alone done. Every time I started asking questions my preceptor would say, "don't need to ask that" and so I didn't. I wish I had some sort of exciting story to pass along. No real interesting pts either (not to say all patients aren't interesting), there was however a 23y/o recovering heroin addict getting ready to go into surgery (managing that pain control should be interesting) and a 14 y/o with a Salter II (partially through the growth plate) femur fracture from playing basketball and another kid hit his leg with a knee. Ouch. Maybe better luck tomorrow.

NW Weather

Rainy, sunny, cool, warm, HOT! What a range of extremes, although being from the midwest this isn't anything special, but out here, when it's hot it's hot, and with no AC it's tome to do anything to stay cool. Cubby has survived one AC-less summer with highs of 110-112, but little Wrigs is still adjusting - at least she has white fur, but then again that just makes her prone to sunburn so thank goodness for puppy sun block. Speaking of sunburn - it's really easy to do out here, it Can be a warm 80 here and partly cloudy and still manage to burn. Yesterday it was hot, like 85 degrees and today I enjoyed the afternoon off at the pool in a cool 96 degrees. One day we will have a yard and a kiddie pool so the dogs (and kids one day) will enjoy the water too. Shawn and I were only outside for about an hour, and Shawn was a little medium rare from the day before - but that short 60min was enough to make me a little rare too. I think Shawn is glad he is working nights for a couple more shifts during this unusual May heatwave, although it's still warm he doesn't have to haul people in the blazing heat ( I don't think the snazzy looking uniform gives much breathability).
Today I had an abbreviated day in clinic. I was suppose to round with my doc before clinic this morning (I more or less pleaded that I wanted to round with him). We were to meet at 8am. So I arrived just after 7:30 so I could do a little chart review before the Dr. arrived at 8am. But as it turns out, it's shift change for the nurses, so no one want to help me find my pt's chart, and since it's not time for Dr. to be their yet I just stand against the wall and wait. I see my pt's name on the wall and just peek my head in and say hello. We (hahaha, not me, I just watched, but I was a good watcher) did a total knee on her on Tuesday. We chatted a bit about how everything is going only to find out that the Dr. was in to see her about 15min ago...hmmm, is she confused (she was a little on the loopy side) she also had to potty. So I finally tracked down the nurse (it's 8am now - the appointed rounding time) and asked if the Dr. had been in - yep he had, about 7:30, I let her know my pt has to use the restroom and she reluctantly tells me she'll get around to taking my pt to the bathroom. realizing I have pts in the clinic in 15min and I seem to easily get lost I trek back to the clinic to find the Dr. there on the phone, he tells me oh I got up a little early and went without you. I was so upset! I had actually been at the hospital since 7am, and I was watching for his car which he parks in a loading only zone but never saw it. There is no one in the office until 7:15, which is when I drop my bag off in the office, so my question is, did he purposely go without me or did he really just want to get it done? Who knows. We only saw about 20 pts today between 8:15 to 11:15. I got to put more bandaids on, pull the xrays and MRIs off the light box in the room and oh yes I even got to hand out a pre written prescription for naproxen (an anti-inflammatory) and prescriptions for PT. whoo. (unenthusiatically). II had a couple pts today who scoffed at the thought of me going through PA school with remarks such as "oh so you're a glorified medical assistant" and "what a waste to not go through medical school and become a physician" As the head penguin in Madagascar would say: Smile and wave boys, smile and wave - and that's basically what I did.


On a side note, American Gladiators is relatively entertaining, especially since one of the new gladiators is from OR, but I just realized that although the gladiators and contenders are of great physical prowess (and Helga is just plain scary), the referee is a little on the tubby side, seems like they would have chosen someone a little more athletic looking, but I guess it just shows a better contrast...I don't know, just made me chuckle. And the new eliminator is awesome and tougher!

3 full days and then some

So before I jump into talking about myself, which I tend to do I should talk about Shawn and life - since it is our blog although I am pretty sure he forgot about it and will never contribute directly to it. Shawn's working nights, but he's finished his FTO which is awesome, so now he can alternate pts with his partner. He's not too fond of nights, although he picked up a day shift yesterday and thought nights were better - no traffic, although the clientele seemed to be a bit different. He's had 2 field tubes and given lots of meds. The protocols up here are advanced and the area they cover is massive which means very little downtime and lots of calls - 11 the other night in just 12 hours!
Cubs and Wrigs are good, this mini heat wave of 90 degree days are rough on both of them - thank goodness for our floor fan. Wrigs is recovering great from surgery, her scar looks much better. They've adjusted well to the new place and even scoped out the park not too far from us which is really big and hilly - lots of room to run but that means we have farther to trek to keep an eye on them.

So it's day 4 of week 1 of rotation 1. I was with the ortho doc today - we saw 45 pts, holy cow; in one room out another. For school I am required to log all the pts I see and I could hardly keep up writing the basic info down so I can log them - whew. This guy is crazy, in and out in and out in and out over and over. On one hand I think wow, this guy is doing great, he started 30 min late due to a scheduling error and manages to finish only 25 min behind and on the other hand I think holy cow, I would feel so ripped off if this were my doc. $45 for an office visit - or more depending if you are new or established and if the visit is focused, detailed or expanded (stupid level of service charges) and he's only in the room for a couple minutes - but he says all he needs to and answers questions - so he is really good to the patients. Today, we were too busy to for him to actually explain much or let me do anything but put a bandaid on injection sites - but on the other hand I found I listened well today when I got pimped at a "business lunch" by a (7th day adventist) family practice doc in his 60s (he made it a point to let me know his religious affiliation). He asked me what the operative options are for a MCL tear and what I would do if my patient had a lateral collateral ligament tear and why. Anyway, I do feel confidant in locating the ligaments, cartilage, bone, tendons, arteries and muscles of the knee in an MRI, so hurray!

Yesterday I spent half a day in surgery with a huge case - a total revision of a TKA (total knee arthroplasty). It was an awesome case! We started at 7:45 and finished right around 11:30, wow. So this pt had a new knee placed a while back, but it wasn't really placed quite right so Dr. H (the doc I'm following) had to take out the old knee and figure out a way to put in a new one. It seems simple enough but it's really quite complicated. First there's the cement which must be cut out, then there's the bone and tissue breakdown that occurred because of the poor placement, this breakdown means there is no sturdy bone in some areas to adhere the new prosthesis. So all in all there was a lot of leveling out bone, building up bone with cadaver bone chips, and lots of hammering, and drilling to perfectly place a new knee which unfortunately had to have "stems" (pieces that go into the shaft of the bone to hold them in place) but I think the patient will be good as new! While this was great, I don' think it compares to my first day of surgery experience on Tuesday...

The morning started with a TKA (total knee) then a Rotator cuff repair (really wicked tear), then off to another hospital to finish out the day starting with another rotator cuff repair, followed by two knee arthroscopes. Morning went without a hitch and with me staying on my two feet the entire time (no face planting today!) I have to add that the doc and PA were already a little peeved knowing they had such a full surgery day - which wouldn't have been too bad if we didn't have to go from Portland to another city about 20min away, and to add to this insult they hate doing surgery at this other hospital due to the poor medical staff and help available. First case is the shoulder - a 600 lb man who didn't fit on the surgical table. Well the patient wasn't prepped the way he should have been (he was super hairy and they had all the important medical bracelets on his operative arm), then one thing after another seemed to be just a little off - which I have to say is not good for a doc who hates change. The doc and PA went to scrub and the doc says, Jen, have you scrubbed before? I said yes (yeah in a OR during school, once, but no pts were involved) then he said I'm going to need to to scrub in on this case. What?!?!?! I thought, I'm only supposed to be observing.... so he finishes scrubbing and the PA says, as I begin to scrub - you don't need to do the whole 20 scrubs on each plane, just get each plane and hurray up, we are all waiting for you. So I scrub - and as thoroughly as possible, Candy Randolph and Gietzen would be proud and I tromp into the OR waiting for the grumpy scrub nurse to hand me a towel - you know a lady is grumpy when the doc asks for a new scrub nurse. Then I find out my job: I am the arm girl - my job is to hold this ginormous arm (and no I am not exaggerating - it was bigger than my highs together) in downward traction - if I let up just a little bit, the sutures won't be tight and he has to start over, plus I have to rotate the arm medial and lateral on queue with the same parameters. So I'm feeling pretty good, all I have to do is focus on the arm - no big deal...which was all good until about 15min into it when my arms began to shake. My biceps burned as did my forearms. Then I'm told to hold the arm up - above my head - but careful don't contaminate yourself (the sterile field can be a real pain to maintain), so the next 15min involve me holding this huge arm steady above my head. Then back to out and down traction (apparently the position is the same as if you were water skiing - bent knees, fairly straight arms, pulling back with your weight). Sweat dripping and arms trembling I manage to do my job - fairly well (my arms hit fatigue and the doc had to reposition the pt a couple times - but oh well). So for my first time scrubbing in I was actually incredibly useful.

1st Impression standards

Well it's safe to say I have risen the bar of expectations for all future clinicians. Today I started my first clinical rotation/residency in orthopedic surgery. I was incredibly nervous. I wanted to make sure I arrived in plenty of time. First patient was scheduled at 7:30, so naturally I arrived at 6:10, then drove around the parking lot deciding where to park, only to park and move my car after security said I had the wrong color tag to park there - even though that's where I was told to park. Thank goodness I arrived plenty early just so I could move my car and meander my way to the office where I sat and ate my breakfast at 6:45 until the first person arrived at the office a little after 7.
It was a light day - and lots of SynVisc injections (a substance that acts like the normal fluid in the knee joint space). And then patient number 11 - our first post-op review of the day, the pt had had a gnarly rotator cuff tear - one of the worst I guess. So we took off the bandage and cleaned it up - aside from the grit, and bruising it looked great! The PA I am rotating with started discussing the PT exercises the pt could start doing and then when I woke up, I had no idea where I was - the room was finishing a spin, I felt chilled and shaky (sort of like the reaction I had to the medication Shawn gave me when he was trying to fix my nausea with an IV, a liter of fluid and medicine in our bathroom, but that's neither here nor there so back to the story). In case it wasn't obvious, I fainted during pt number 11, fell forward, hit my head on the exam table and then to the floor. That's one way to make a first impression and a small lac to my head as a reminder. Oh I can't wait for the first surgical case tomorrow! Sorry folks, no pictures...

New beginnings

Well, 4 moves, 4 states and 14 months later, we've settled - again. We just moved to Vancouver WA. Shawn is working at AMR and loving it. (Maybe not the night shift, but I think working the night shift takes a special breed). I just finished my didactic year for PA school which is rather unsettling. I am expected to know so much at this point and yet I really feel I know very little. So for both of us, a lot of changes. I know I haven't kept up on this posting thing, but I have committed myself to it for at least my rotation year. I will be spending a large majority away from my husband, which is really tough to stomach at this point. So, I figure, I can write/type away hoping it will capture the next 15mo which is sure to be quite a ride. I am just so grateful to have Shawn by my side the entire way. And I know Cubs and Wrigs will be in excellent hands.
My first rotation is Orthopedic Surgery, which has been a dream of mine since I was 5 yrs old (seriously how many 5 yrs olds know what they want to do with their lives?) I am very excited, but of course nervous. And how much can really happen in 6weeks? The time will fly by so fast I just hope I can make the most of them.

As far as our moving... we seem to like it out here. I can seriously see us staying here. It's funny because this is our 3rd apartment and we are still moving up so to speak. We started with an open plan, almost studio like apartment (only door was on the bathroom) and tiny kitchen with few cabinets, oh and we lived sub-ground level, next we moved to a much smaller and more expensive 1 bedroom, with actual doors, walk in closet and a washer and dryer and a patio to grill on. Plus some other amenities like a pool, and workout facility. Now we are living in a 2 bedroom 2 bathroom apartment with an actual dining nook, washer dryer, awesome patio, amenities and we even bought a new couch and chair - I feel so grown up now. How silly. No matter where we move, no matter city or apartment, as long as we have each other we are home.