It's official!!

That's right ladies and gents it's official, I will be doing my next rotation (#4) in Portland! Funny how things work out. I was originally going to be in TX another 6 weeks (which at the time meant I would ship my car down here to drive up to KS and then to IA), then that was changed to ID( ok, so it screwed the car shipping idea, but saved me money and I would only be 8hrs away from home), and now Portland for a trauma rotation! Woohoo!! I have already noticed a boost in my morale knowing that not only am I counting the days to get out of this God forsaken land known as Texas but I will be going home for 6weeks. And even though I know the hours of this upcoming rotation are going to kick my butt, at least I will be home, in my own bed with my husband and the dogs. There is nothing more comforting than that, well maybe the fact that I will be at home during baseball playoff season - like a cherry on a sundae.

I have a big presentation tomorrow that my preceptor assigned me - talking about the approach to anemias and differentials. Whoo hoo (sarcasm anyone?) I got up today at 4:45 to jump on the computer first (it's tough to get the Internet around here with 3 teenagers) and do some research, including cutting and pasting from my online textbooks. I did some research and reading yesterday, but I went to one of my cousin's 6th (Olympic-themed) birthday party which inadvertently lasted for almost 7hours between the hour and a half party at the gymnastics place, going to my cousin's house to unwrap presents and then out to dinner. On the plus side, I got to do some flipping at the gymnastics place, which is a great release of energy and so far my body doesn't hate me for it. So onward ho I go! Once I finish gathering my info not only do I get to put together a reasonable presentation but then I get to enter 70 patients into Typhon! OH goody, I can't wait!

Go Cubs Go

Chicago was awesome! Shawn's parents and the two of us saw two of the most amazing games ever, not to mention our incredible seats! The weather was perfect while we were there, not too hot, but sunny and the clouds and wind came in after the second game on Sunday. We left the city before the tornado brushed Navy Pier and cleared out Wrigley Field on Monday, but not soon enough as to miss the thunderstorms which consequently delayed our flight a couple hours.

Shawn's parents are Cubs fans too (although they don't have two dogs named for them to prove it). It was there first time at Wrigley Field. Karen (Shawn's mommy) was just hoping for a win out of one of the two games so she could hear and sing Go Cubs Go at the end of the game. Well, lucky for her, she got it both days. There really is nothing better than being on your feet almost non-stop through a baseball game and nearly losing your voice form the yelling, cheering and singing.

Although both games had their high and low points, a couple key players were clutch in both games. First, my favorite center fielder Reed Johnson and the rookie catcher Geovany Soto. Big Z pitched a great game on Sunday too. Johnson should get a raise for his clutch batting moments for these two games alone. So in game two, Cubs are tied, 5-5 (thanks to Soriano making a half-assed play earlier in the game), it's the 7th inning. Daryl Ward was suppose to come in and pinch hit, but wait, there's a pitching change and Lou decides to bring in Johnson to pinch hit - and he hits the game winning two run homer!!! The crowd went wild!!! This is just one of the many on-your-feet moments of the two games.

So after our fun-filled, adventurous weekend, we go back to our hotel to get our luggage and travel by the L - the train - to go to a hotel closer to airport. WE had taken the train in and around town, no problems, it's a little more complicated and confusing than the Max but still cheaper than a cab ride (and usually less sketchy). So we are on the train, waiting for our stop to transfer to the red line. Something doesn't feel quite right - can't put my finger on it. I suddenly felt like a minority on the train and their were a couple sketchy guys on there too. Our stop is next. All of sudden, some guy starts walking in front of us messing with his pants, doors open and he doesn't move from standing right in front of the door. I try to say excuse me, but he ignores me as he continues to fiddle with his pants. I finally push past him and walk out with my luggage. I look back to see a commotion behind me only to find out later that the other guy and train tried to snatch my mom-in laws purse as the other guy distracted us. Luckily Shawn's quick hands grabbed the offenders arm and saved the purse, we were lucky that everyone involved returned to the train, being below ground a few stories is the wrong place to be to have trouble. We have a couple flights of stairs to go up to get to the next platform - everyone was breathing a sigh of relief that we had escaped a major catastrophe. All of a sudden their are some 20 young kids (ages 13-17 or so) rushing up the narrow stairs were on (with all of our luggage), they're pushing and shoving and somehow I get knocked down and trampled. Shawn quickly snatched me up to save me from being more injured than the bruise and scratches on my elbow.
We decided that at this point we should just take a cab home. It was very scary and tainted the end of trip. But other than all of this the trip was AWESOME!

This the Cubs' year!!! I love the Cubs, but I don't want to be in the city when they win the series, there will be riots, and they may accidently burn the stadium down.

(This post is a little late, things got a little crazy after we got back, like school and rotations starting again so Shawn's harped on me long enough to finally finish it. )

I love prison! (but I love my husband more)

It's never a boring day in this rotation (4 days in), never. I was so afraid I would have to journal about the landmarks I use to get to work and make the right turns along the way (which are in fact interesting themselves, so that may come one day)

I'll cut to the chase, here are the TOP 4 great things about today's work (I had a hard time putting these in perfect order, so I consider them all close to equal)
4. 30 with new onset DM based on intake labs and random finger sticks - seems run of the mill but he was the first patient I have yet to have that actually was concerned (tears in his eyes) about this diagnoses and wanted to know how to "beat the disease." It was fun educating him about diabetes and how losing weight (5'7, 256 lbs), exercising by walking vigorously in the yard and taking control over his medications for HTN, Hyperlipidemia and now DM would be very important, as well as checking his feet daily and keeping them dry. I hope he keeps his motivation.
3. The patient was seen on intake a couple days ago and complained of being nauseated and vomiting, a few of his intake labs looked a little off, so some repeat labs were ordered, and in only a couple days his labs became even more skewed from severe dehydration in the last two days. Even with his phenergan (anti-nausea med) he wasn't able to keep anything down. So it was time to ship him off to one of the prison hospitals. Knowing it would take awhile (5hrs in the end), we decided we could start by giving him a little IV fluid to help rehydrate him. So I was sent to escort him to the "ER" room in the unit and start this order. The pissy nurse reluctantly agreed to do it but verbally complained that it would be impossible to start the IV due to his dehydration, he was freezing cold and he was a former user. She pulled out two 22 gauge catheters and sat down mumbling about her job. (22 is almost the smallest catheter made for adult IVs - normally an 18 would be appropriate for this type of thing) After two attempts with the same needle, and no success, the Dr. walked in and the nurse said, no luck, can't give him fluids, and the doc says, well didn't you know she (meaning me) was a medic before going to PA school? In a huff, the nurse said no and said it's all yours with such a snotty tone I almost offered her a kleenex. I popped on the tourniquet, saw a beautiful AC, politely asked for a larger catheter (to which the reply was you won't get anything in him, so I'm not wasting a 20gauge) I had a brief chat with the patient that if I did get this IV, he would have to keep his arm straight so we wouldn't lose the site, and I was only going to take one stab at it, so he had to hold still. He agreed and with a 1,2,3 count it was in and fluid was running (albeit slowly with a 22, but running nevertheless). It felt good to know I still had my IV skills.
2. Punch biopsy (fancy name for using a small device the has a circular metal blade on one end, place it on the area of skin in question and make gentle twisting motions back and forth to go 1-2mm deep then lift the circular area, snip and send to pathology). The suspicious lesion in question today started 2 months ago with a honey crusted lesion that was oozing, that seemed to appear out of no where, was treated heavily with atbx, which although it dried it up some, the lesion itself has not changed in size and now has a crusty center with hypertrophic edges (sort of looks like thick scarring around the crusty). I did the whole procedure by myself, local anesthetic, biopsy and then...
1. Placing two sutures with 5-0 Nylon to close the punch biopsy - my first stitches!! Finally!


All in all, a great day! And there may be even more great news on the horizon, but I musn't speak of these things yet until another email arrives...

In non-work news, Shawn said he was going to take the pups to the park, I'm jealous. I miss them, and apparently Cubby has been giving him the "I bet you buried mom in the back yard" look - I miss the Cubster (and Wrigley too) but most of I miss home.

there's a moat around our house and lake in the front yard.

It rained last night, a lot. When I woke up this morning I had no idea I would be wading to the miata through the new marsh/swamp that is now the front yard (wouldn't be so bad if there was a sidewalk!). I hardly had time to admire the lake that had formed in the front yard or the moat encircling the house. I suppose I should also mention that the other day when learning to drive the miata I noticed that there are deep runoff trenches along the side of teh road I am living on with no margin for error meaning no shoulder, at all. These trenches are roughly 4 feet or more deep on both sides of the road. I remember thinking to myself, gosh it would really suck if I went off the road and into the ditch. Well, today the ditches were full and overflowing in some areas, I guess they weren't deep enough. I will post pictures when possible.

So here was the list of intake physicals today ages ranging a 25 yr span. I had 40% who had new +TB skin tests, only 2 with Hep C, 2 coming down from heroin and only 1 with HIV. Not too bad. We tapped a knee that had an effusion (fluid in and around the joint) and this guy had his patella removed after a fracture repair went south and became infected. The penile discharge was pretty run of the mill although watching the poor kids face when we said we are going to have to put this long qtip up your urethra (it's only a few cm, really, how bad can it be), a few acne cases, one patient completely enraged that the newbie he had been ministering to and helping find Jesus gave him scabies, and then the last 3 were more interesting. Allow me to set up the first case.

It's loud in jail, especially at night in the dorms, and some people actually want to sleep and not stay up hootin' and hollerin' as is the case of my ex-marine corp pt. So the only logical thing to do at night is to make ear plugs out of toilet paper and shove it in your ears to drown out the noise. The gap in logic lies in the fact that toilet paper was meant to disintegrate/break down when it gets wet. This property of toilet paper doesn't change even when it's in the ear. The humidity allows the homemade ear plug to shrink and harden, shrink and harden until it becomes stuck. Our pt today came in with ear pain and decrease in hearing in both ears. One ear was so full of wax we couldn't get the speculum in his ear, and the other had a thick yellow cottage cheese substance completely obstructing the entire canal and even draining a little.

Next interesting one I guess isn't that great, but I got to the I&D on him, so he makes my top three. Long story short: carbuncle formed on bridge of nose (long standing problem) after his face was reconstructed with bone grafts from his hip following a nasty car accident. The little spot is growing and draining and has grown some interesting cultures in the past, so with an 18g needle and some culture tubes I had at his face. Can't wait to see what grows.

3rd and final guy (perhaps I should have left the earplug inventor for last, this may be anticlimactic), he was in an altercation yesterday and now has no use of the tip of his pinky finger. During his punch he hyperflexed (bent as when you make a fist) and ruptured the extensor tendons at the distal end of the pinky. It's not really debilitating, in fact now he has the perfect finger for nose picking, but the finger is still really swollen and there may be a small area of bone that came off with the tendon, so off to ortho hand specialist he goes (in a week).

That's all folks!

(On a sad note, I hate the 2 hour time difference, I go to work too early to talk to Shawn, and by the time he gets off I"m ready for bed, sigh. I miss my Shawn and the dogs)

My first pat down

Well today, I got my first pat down. One of the two bathroom keys went missing, so security went from person to person patting them down to find it - it still hasn't been found.

I like my preceptor, and I actually like working in the prison - once I get past walking down the "bowling alley" by myself being completely open and vulnerable- the bowling alley is the long concrete yard in between the bunk houses. Walking into the medical facility is equally unnerving, you walk in next to "the cage" which is where the inmates sit and wait (or is it more p.c. to say offender? who knows). In the morning it's full of the new intakes who have come from county. I sort of feel like a piece of meat walking past them, waiting anxiously for the next officer to open the door. Today I had to wait. I hate waiting - makes me nervous. I don't know which is worse, waiting and having to face them, or waiting facing the door, either way you feel like 60 pair of eyes are staring you down.

Pretty run of the mill day - intake physicals and then sick call. We had one deaf guy, one who faked having seizures to get a low bunk (but confessed after realizing how often he would need blood draws to check med levels in his blood) and a whole lot of non specific dermatitis caused from - washing too often with too much soap. This is really common because, well it's hot here in Houston in August, and super humid. These guys wash 2,3 some even 4 times a day, scrubbing with some state given soap that does nothing but dry the skin out. So many of the inmates had "dry skin" or have scratched at the dry skin enough to get a small bacterial infection on the skin or in the hair follicle. I never thought I would be giving repeated patient education on the importance on not showering so often and not using the soap except in the groin and underarms, daily or every other day. Sadly there are no good soaps or lotions available in the commissary to help alleviate this problem, I guess they should have thought of that before they got caught. (I'm becoming hardened already)

So back to liking my preceptor, she's upfront and honest and direct. She has a sense of humor and has been working in corrections since she graduated 25 years ago. She's been in this particular facility for 13 years and once a year she does research with NASA on the vomit comet to see how to mix IV fluids in 0 gravity. She's really easy to talk to and today, for some reason she decided to give me the gossip about some of the other people in the unit - this may sound unprofessional, but I think she was actually using it to educate me on the diverse group of people working in the med unit (it does take a special breed of person) such as - the lesbian wickan couple, or the lady who is a nudist (obviously not during working hours), or the people who's spouse, son, brother or nephew might be in the TDCJ system just to name a few. And these people aren't shy about any of it. Why just today, the nudist lady mentioned something about "thank God I don't have to worry about tan lines, how annoying" mind you she is over the age of 50 - the only image I had was Magda from There's Something About Mary. I suppose I should leave you with that image.

I'm Ms. Zoop-fer

Today was my first day. Despite the fog I managed to make it there and despite the heavy rain make it back in the tiny little miata(although I did managed to get lost on the way home and my family had to establish a small search and rescue mission to find me). I had to wait to be escorted to the medical unit entrapped between two steel doors. Thank goodness an LVN was there waiting with me as my official clearance came through. She gave me some of the most useful advice and reminders: Chin up, shoulders back and last name only. That was a big adjustment to introduce myself as Zupfer (no one has pronounced my name right, but it may be the heavy accents) I also have to learn to ask permission to go to the potty, the security guards hold the key to the throne, I may need to limit my water intake in the morning, I would hate to have to ask for the key more than once in a day.

I learned some new terminology and abbreviations today that I am certain I will never use outside prison: KOP - keep on person, J-up = get a job, FW = free world to name a few. I saw a lot of scamming today to get meds, albuterol inhalers are the hot commodity here right now - it's amazing how the inmates can make sounds that replicate airway diseases, but then again I guess they have a lot of free time so to speak.

Already I have done some exams in Spanish, although not your typical exams, I have to remember to ask the patient to stand up turn around, put their arms up lift their chin and (do the hokey pokey) breath quickly and deeply just to listen to their lungs and I have seen patients with HIV, Hep C and gave an explanation of emphysema and demonstration on how to use inhalers and what they are for. Who knows what my day will consist of tomorrow.

The most difficult part of today was surprisingly not trying to look scared out of my mind but grasping the idea that the inmates here have a right to health care, and in many cases better access to health care than those of us living in the free world. This may take awhile for me to wrap my head around, and more of this to come later.

(And PS- it's pronounced Zup-fer, like zup as in cup)

Prison bound

Well I made it here and so did my luggage. So I'm off to a good start. I am settled into my relatives place which is about 5 or 6 miles from Crosby or Baytown. The set up here is pretty neat in that I am staying with one of my grandma's brother's sons and his family who happen to live next door to the previously mentioned brother and his wife. So yesterday, my first night here, I was able to see some family I haven't seen in awhile and some more cousins and their kids too. Family is so great, I am so lucky to be able to stay with them even though life here is a little different than I'm use to. After sleeping in today, I went to the store to buy some groceries and a lot of ziploc baggies. I have to pack anything and everything in a clear bag when I go to the prison. Today I also received a very important lesson - driving lesson. See originally I was going to be using the family car, then when I got here I was told I would have to rent and then this morning it was decided the family would somehow make the car thing work (which is great because it saves me $1200). The only hurdle to using one of the family's care - I would have to learn how to drive a stick. So after dinner, Tim, the dad, took me to the primary school parking lot for me crash course in how to drive the Miata. I did pretty well having never driven a standard before, and I didn't kill the engine until I had to reverse to turn and then go again, unfortunately I killed it perpendicular to traffic - maybe I need a sign that says student driver. And after only 15minutes of circling the parking lot Tim took me to the highway where I opened it up - ha ha no - but I did manage to get going up to 60 with relative grace and style. Then it was back home. So now, after my 37minute crash course in driving I am ready to hit the open road tomorrow, throw the top down, sunglasses on and head to prison. Can't wait. I am pretty nervous about this rotation, although if I weren't nervous I would think something was seriously wrong with me.
Despite all the fun I had today, the best part was talking to Shawn. I feel homesick already, I swear I feel like I have been gone a month. As soon as I got on the phone with him he said "wanna hear Wrigley bark?" and she did with some persistent growling as well. He had her so wound up before he got on the phone with me so I could hear her. It was very sweet, but it did make me miss the three of them (especially Shawn) all the more.
Well, it is getting late, I should probably get some rest before the big day tomorrow. And now that I think about I'm not sure if I am more nervous about driving or the actual rotation. Beep Beep.