Implanted Radio Frequency Devices

IRFD's (see title) ya know, the things that are involuntarily implanted somewhere inside you, usually via tick ingestion and placed without consent - well I guess some people want these removed, but I (me, Jenni) don't really know much about that because I'm not educated in artificial intelligence and chip-like devices I am told by my patient. WHAT?!?! I hope the reader is as confused as I was when my patient was telling me this.
The MA's in the clinic are great where I am, they give a heads up when a pt seems odd or perhaps a drug seeker risk. We don't keep drug seekers in our clinic. In fact we don't even prescribe narcotics on the first visit, and sometimes not the second, but anyways, the point is the MAs are usually right on about patients. So when the MA told me today that she thought the patient seemed a little odd - I should have given her a little more credit. I went in the room with a completely wrong attitude - or rather, with my guard down. Anytime a new patient comes in with Migraines and joint pain, the level of suspicion is up and so keeping that in the back of my mind I did my H&P, which suddenly went places I couldn't imagine. Stories of holes in stomach, surgeries against a pt's will in which a foreign object was placed such as IRFD, and desiring to have an abdominal US and MRI of the head to find other implanted devices all with an element of disconnect. There was some other interesting history too including a prison stay, asking for pain meds and having burning and numbness in non related areas and occasional rectal bleeding. I was totally lost as a student. I did a complete exam, really trying to find something to report back that made sense. I thought the pt was just a tweeker - kinda seemed nervous, and a myriad of symptoms that didn't make sense. I even tried asking some of the most direct questions I have ever asked to no avail. So dumbfounded I reported to my preceptor with my tail between my legs. My preceptors questioning was even more to the point than mine and the disconnect even further and soon the questions weren't even being answered but merely an intro for the patient to diatribe into IFRDs and having holes in the stomach and people holding him down and waking up with foreign bodies in his head. Then came out the big dog questions - the psych questions. (I'm an idiot I thought!) Although I had dabbled there, I was so focused on beating out a narc seeker I kind of missed the obvious. My patient was delusional! To shorten a very long story, the pt was referred rather immediately to psychiatric care - whether the pt actually goes who knows, but needed medication and observation - badly. Turns out this kid (younger than me) is an ex-meth user who lost his brain to drug-induced schizophrenia. WOW. Can we say blind-sided? Craziness. So, moral of the story - don't do meth. Oh and P.S. to this story, if a patient needs to suddenly use the restroom, and you ask them to go in a cup, just in case we need it later, you may want to remind them that if they aren't going to actually give urine in the cup, at least use hot water and mind the cuff of their shirt when filling the cup.

In other clinic news, my days have been far from dull. I did my first full exam in SPANISH (I can't imagine however painful that was for the patient - I imagined a 4yr old giving a lecture on brain surgery to neurosurgeon fellows) - unfortunately I just don't know how to discuss exposure to infectious diseases in Spanish, but did manage to come to the conclusion that it was possible TB - and I'm not sure what the cavitary lesions on the CXR are from, I can't wait to get those results back. I reported my first patient to public health - sadly that patient has yet to fill her prescription yet or make a follow up appointment (I guess some people don't mind the foul discharge). I may have seen my first skin cancer which (if it is truly cancer) has already occupied nearly half the face along with a 5cm mass on the back of the neck that has been growing for 6mo - but wasn't a concern for the patient since he can't see it in the mirror. Finally, a pt with cerebral palsy and severe mental delay offered me her baseball helmet that she wears for safety only to retract her offer with a "I don't like your pink socks" quip. Interesting considering she was wearing pink pants, a pink helmet, pink shirt and white shoes and socks all with pink. Oh, and did I mention that the hypernatremic patient in the ICU didn't make it to Monday? She barely made it to Sat morning. I was a little bummed.

A rock in the ocean

Yes, I would say that describes me right now in this stage of my training. Why a rock? Well, sometimes it's seen - if it's a big rock, but can easily be beaten by the harsh conditions of the crashing waves, sometimes even disappearing altogether. Secondly, if you throw a rock into the ocean, odds are it will sink and rather quickly to the bottom of the ocean. It may wash ashore at some point, in some form but most likely not. All that being said, I feel like a rock but not in the steady/sturdy sense. A few small defeats this week - I missed hearing faint crackles in the bases of an elderly ladies lung - I mistook it for my stethoscope rubbing on her shirt, I realize I have no clues about certain labs, but occasionally I order one or two that although long shots have merit, and I don't know dosages or best choice atbx off the top of my head which is frustrating. On the other hand, I have had a few small victories this week too. I found an air fluid level in an ear and bubbles behind the tympanic membrane, I also found severe hearing impairment in a wanna be truck driver (he couldn't hear the Weber test at all!!) - which consequently disqualified him until the audiologist sees him, I have even managed to make a big diagnoses this week ...drum roll please.... new onset seasonal allergies - oh yes, have a little Nasonex and Zyrtec. One of my other small victories is the amount of patient education I get to do - almost every patient talking about better food choices and a few naturopathic remedies my preceptor suggests. I've talked about those darn food choices so much we have completely changed how we eat at home - I felt like a hypocrite and fraud, so had to make the same changes I was endorsing.

I have met some really incredible patients and even have some "favorites" although I know Prof. LaBoy would be in disarray at that comment. I have even grown fond of a couple inpatients I have seen. I almost have too much freedom with the inpatients - why don't you go see so and so, write a quick note and recommendation, I'll read it later and then we'll discuss says my preceptor. So I have seen quite a few patients - by myself and (cringe b/c this is probably not all that ethical) without my doctor in-house. I realize it takes me frickin' forever to write up a "QUICK" note I have to sift through the chart, find the info I want, look somewhere else in the thick chart when I don't find it, write a little and look some more, it's never ending - and this is just the note, not to mention my exam and pt questioning. My 3 page SOAP note took almost 45minutes today (and I had to ask for more progress note paper - oops) - it's ridiculous - but to my defense, I was interrupted by the wound care specialist and the cardiologist and I had to make a lame attempt to interpret the lab report of 11oocc drained from around my patient's lung yesterday and the patient has a laundry list of ailments (admitted for a stroke, Afib w/ coumadin failure, CHF, dysphagia, and massive right pleural effusion). I guess my diligence paid off today I was praised for my thorough note and comments from various specialties. But still, 45min is unheard of.
One more brief note about another inpatient that I have found fascinating: admitted for pancreatitis, suffered a massive posterior occipital-temporal stroke, they found a large mass head of pancreas, major neuro deficit now, on bi-pap, major ascites in abdomen (the ascites is growing a strange yeast which is considered obsolete), and now has increasing Hypernatremia (160) with cause unknown. Seriously this lady should be dead if you went by the numbers and percentages. I am anxious to see if all of this is caused by Cushings, Diabetes Insipidus, some type of tumor or what not, although the neuro people said with such a large stroke the hypernatremia is pretty common, they aren't rooting for her speedy recovery - I hope she makes it to Monday.
So as I recover from my writer's cramp today I can push thru Typhon knowing I was given the weekend off!

( I took that pic of haystack rock - it actually looks kind of cool)

Time Flies

I can't believe this week went so fast! Even though my days are long with a very long commute they seem to go by so fast. I am seeing lots of patients solo which is such a relief. I'm in no way ready to be on my own in the real world, but at least I seem to be able to squeeze the important things out of pts even if I have beat them with my stethoscope - no I don't really do that. I get so caught up in the questioning that a couple times I forgot to do a physical exam - what a dweeb cheese I am! I feel like such an idiot when this happens, but hey, I'm on a learning curve. I have lots of things I need to review and remember. I have a hard time with Pharmacology and ordering and interpreting labs. (guess I should not have crammed pharm the night before all year long - oops). This week I heard a couple murmurs, did a pap and breast exam all by me onesy (and even found pathology!), I am also starting to see more complex patients. What's even better is most of the patients I have seen this week I will see again! The doc I am working with seems to thank me for my help - which I find a little odd. He gets really behind on his paperwork and uses my notes to dictate on patients which is fine. Maybe I find it odd since in my last rotation when I was the Bandaid/Xray retriever I never was thanked or told I was doing well. I hear this a lot now which is a nice offset to before - even though it's not necessarily warranted.
I am so grateful Shawn has been encouraging me through all of this. He told me to hang in there during the last 6wks and reminded me I chose the right path going to PA school, now I am finally able to say that too!

The end of an Error

I had a little extra bounce in my step last week. I finished my first rotation (or error for a crappy preceptor). This would have been enough for me to be excited, but even more so, the end of my ortho surgery rotation means time to move on to a preceptor who actually cares about students and doesn't find women inferior (I hope). I have to admit, this rotation wasn't all bad, like the whole 5th week when my doc was out of town, I spent 3 days in OB and got to assist with a couple C-sections (pretty darn sweet!) and do lots of measuring of pregnant bellies and listening to little heart beats, I also got to go with two other ortho's saw some Hip replacements (6 in one day to be exact), a knee replacement, lots of knee scopes and a ORIF of a distal radius fracture (open the wrist to put in a plate to hold the end of one of the forearm bones together with plate and screws). I even got to see a PA actually do something in the OR - like suture and be an integral part of the team, not just another person in the OR. And another great thing about my ortho rotation, there was a pizza party in my honor the last day, not to mention many business lunches at nice restaurants. So see there were some positives that came from this rotation - even if the doc made me visibly cry during one of the last surgeries I assisted with (so much in fact my face shield fogged over and was collecting tears like a reservoir), I think he even mentioned something about me "not cutting it" and how "ortho may not be for you because you have to have physical strength and know how to do what I tell you to." So after writing a candid email to the clinical team, I moved on to Internal Medicine.

I had thought internal medicine would be my arch nemesis, and it may turn out to be just that - but I'm not stuck in a hospital but in a very low key, slow paced clinic with a first time precepting doc. Yesterday was my first day, kind of a short day with only 4 patients since i had to go to a mandatory computer training for software that won't be up and running until my last week in the clinic. Hmmm... But anyway, even though there were only 4, they were a great 4 - including an exam entirely in Spanish and a well baby visit. Today I got to see a pt in the hospital post liver and kidney transplant, AND... a couple patients by MYSELF; a pt with dizziness and a new pt establishing with a new PCP. I may have been long in my exams, and I may have missed a few questions, but I went in all by myself! yay! I also got to do the exams of more complex patients. It was a great start and a much better rotation so far!

More change

We were going to have steak tonight and watch the Cubbies play (who couldn't extend their streak to 10 in a row), but as Shawn opened our yummy steaks a fly flew out of the package - ewww!! Just another reason not to eat red meat - even organic meat. So we will be eating BBQ chicken instead.

Today I saw a cool surgery - an ACL reconstruction with an autograft. So the pt had a torn ACL and meniscus, so the surgery started out like a scope, then the anterior (front) of the knee was cut open very carefully, and then the middle third of the patellar tendon was harvested with a small chunk of tibia on one end and a little piece of patella on the other. The graft is manipulated and drilled for the suture in each end while the drill holes are made in the tibia and femur. A guide wire technique is used to thread the graft into place to form the new ACL and then is anchored in with screws. Here's two links to give a better idea: http://www.nytimes.com/slideshow/2007/08/01/health/100230Anteriorcruciateligamentrepairseries_index.html
http://www.emedx.com/video/VideoPages/ACL%20Surgery.htm (video)

I found out today that one of my rotations has already changed. I was suppose to be in TX for 3 months for back to back rotations and now I will be in TX then ID. IDAHO??! So bummed as I am since I practically had all the logistics settled for being in TX for 3mo then KS for 3mo, I am trying to look at the bright side of things. I will only be 61/2 hours from Shawn so I can see him every other weekend instead of only once or twice in TX. This will also be good for the doggies. So, that being said, I am bummed b/c I have heard that the rotation I would have had in TX was awesome, and now I have to rethink logistics but I will be closer to home, so yay! Hopefully none of my other rotations will flip flop on me.

Zoo Brew/Save the Roar

I had Friday afternoon off and came home, Shawn made his famous waffles and I made my famous whip cream. YUM! The afternoon was looking better than the morning had started - Wrigley had poo'd on the bed while Shawn was sleeping - not a great way to start by any means. So we were contemplating when to go run and Shawn's phone rings. I am the worst at deciphering half a phone conversation, but Shawn whispers to me "brew fest" and shrugs his shoulders. When he finally gets off the phone he said it was one of the guys at work (one of the supervisors) and he wanted to know if wed be interested in going to a brew fest at the zoo. Now, for two people who don't drink - and beer at that, this sounded like a rip roaring good time - except not. But, this guy has really done a lot for Shawn, a lot - in fact he's one of the sole reasons Shawn started working for AMR when he did as he was being screwed around by the state for licensure. So we looked it up online to get more info. The event's called ZOO brew - all proceeds go to bringing back Lions to the Oregon Zoo. So I was sold - it's for the animals, plus maybe I would get to see some of the zoo.
So we arrive to the zoo get our tickets and our wrist bands and head toward the party, hoping to view the animals along the way but it appeared all the animals had gone inside fro the night except for the fat sea lion that was laying on a rock, some monkeys who had been given a phone book to play with and some brown packing paper. We went to see the polar Bears, but there were none, but instead of the polar bears, in their habitat we saw a hard hat and industrial bucket and plastic crate in there, so our question was - what happened to the person wearing the hat?

Overall the zoo is less than impressive - but then again we are comparing it to the Omaha Zoo - which is awesome! The layout is set within the woods - it really has a lot of potential, just not a lot of sparkle. Oh and did I mention the "Insect Zoo"? A section of the zoo entirely dedicated to insects - like hissing cockroaches, ladybugs and spiders. Hmmm. It was a kiosk/tiny hut with little bug houses - most of the bugs I had in my 8th grade science classroom.

We got really cool glasses that have Zoo Brew printed on them and 9 tokens to taste to our hearts content. Like our usual fashion, we started with Root Beer - it was ok... we decided to go for a little walk to see the elephants. One elephant was outside enjoying the immaculate weather, the other was inside eating. This may seem relatively uneventful but this elephant was special in that it was sporting his extra parts for all the world to see... TICKETS TO THE ZOO$40, TICKETS TO ZOO BREW $60, SEEING AN ELEPHANT'S PARTS HANGING TO THE GROUND (and all the adults laughing while children looked puzzled about the elephant's 5th leg) - PRICELESS

We met up with Shawn's friend and his wife and sampled here and there, they told us about some really neat things to see and do in the area. Afterwards we decided to go to dinner with them (it was like 9:30) we stopped by the rose garden and although nothing is in bloom, it was still pretty, even at night - you could still see Mt. Hood too. Then off to Lauralwood brewery for dinner in a really trendy little area. We had some burgers and fries and called it a night. We got home about midnight and it was then Shawn realized he had no clean clothes to wear for work for today - that made get the giggles. What a day, some good spirits, good company, a little elephant fun and we saved the lions all in one night!

Memorial Day weekend

It was so nice to have the weekend off together, Sat-Sun!! Whoohoo!! We even slept in alittle. The weather wasn't great, and sicne gas hit $4 a gallon we stayed close to home. It was so peaceful and relaxing though. We also rented the movie Juno from the convenience of our couch and No Country for Old Men. Our opinion: JUNO - two big thumbs up!! It was hilarious, dry humor. Already we've found ourselves quoting it once in awhile - which is always a good sign for a good movie in our house. Shawn bought orange tic-tacs the day after - I couldn't help but call him Bleeker. The other movie was, um, well, interesting. There are no other words. Just interesting. Not what we expected and a little more bizarre than we anticipated, but the airgun was pretty darn cool. It also had a bizzare ending...
We also had a thunderstorm this weekend, lightening and thunder the whole thing. I really miss thunderstorms in the midwest the storm here wasn't impressive like many of the storms back at home, but it was still enjoyable. It was the first time Wrigs had ever heard thunder - so she felt the need to bark at each clap of thunder.
We also explored a new dog park close by, it's not like Hondo, but it was nice and not too many dogs. There's a little trail around the park to walk around in a circle and amazingly the dogs stayed quite close when we walked around and even came right to us when called (Shawn's so smart to remember to bring a couple little treats when we go places).
And finally, the Chicago Cubs are kicking butt. 100 years is long enough!