Starfish of Death

Not an actual medical term you would find in Harrison's (trust me I looked) but cool none the less. Pt synopsis: single motorcycle crash - wearing a skull helmet - found down w/ agonal respirations was flighted in oh and body habitus = 120+kg. End result: skull cap helmet NOT effective, massive head bleeds, so much in fact in several vies of the CT there is no differentiation between the grey and white matter and you can't see the ventricles in the brain - bad sign and in several CT pictures the starfish (of death was pointed out). Other than the massive head injury nothing else going on. Lifeflight needled her 4Xs - and missed the pleural cavity with all four due to body habitus. She didn't have a pneumo though until she was getting PEEPed. Then two attempts at a chest tube. Literally this pt was was a small framed gal with a fat suit on - where you would think the 6th intercostal space was based on her size was in fact the liver/diaphragm - which I felt when rummaging my finger in the hole trying to feel the lung.
I also got to staple her head shut which was interesting trying to maintain C-spine and staple her occipital lobe nadn I watched a bolg be drilled into her head which measures intracranial pressure using a hand drill you can buy at Lowe's or Home Depot.
We also had a pedi trauma, which come to find out was a clark county original - not Shawn's but kind of fun to share patients. Speaking of Shawn. He worked 2a-2p yesterday and his usual 7:30a-p 12 shift today and tomorrow. I basically got home in time to say good morning, I love you and have a good day. This rotation will suck for family time for sure and I will be feeling these long hours for a while even after I'm done. I'm also still trying to save my brain - one antibiotic at a time - now I've got super high doses of septra too oh joy!

I saved my brain today.

The last 3 days my nose has hurt. Not like rubbing my nose too much and it's raw, more like I got smacked in the nose super hard. Sometimes I think I might be borderline hypochondriac - although I don't usually complain until it's really bad and then I start to read. Reading can be good, but I have tried really hard while in PA school not to over-read or to hold other clinicians to the same level that I treat patients - thoroughly and with up-to-date knowledge. The nose thing started abruptly, no digital trauma or any type of trauma except for maybe a week ago one of our dogs accidentally bumped me in the nose - but it never got sore. Then my nose started to bleed a little, then last night I ran a little fever and was a little pukey. Today, my cervical LN are sore and it hurts my neck to lift my chin. I've already done the research and my primary concern: facial cellulitis. i then notice a slightly erythematous area on the bridge of my very sore nose that's a little warm. I had to give in and go to the doc. Shawn was super proud of me - I hate going to the doc and pretty much never go unless it's life or limb. To make the appointment I have to try and explain these symptoms as concisely as possible and words get lost in translation and when I arrive to my appointment the MA says "so you have a cold huh?" Um, NO. My heart rate was 125, temp 99 and BP 110/70. The MA was sure the pulse was wrong but I could feel my heart racing in my chest as it done in the last 24hrs. Once again I tried to explain things to her. I don't think she was even listening - you can't listen if you are interrupting. (LaBoy's golden rule right? - Just give me 90seconds for goodness sake). Provider comes in (NP) - so I hear you have a little cold. Strike #2. I really hope I do a better job listening to my patients than this - how annoying. After I proceed to tell her how my nose hurts too bad to even touch it lightly she wants me to lay down to jam the speculum in my nose. Seriously? C'mon. She feels my cervical LN which are grapefruit size (ok not more like shelled walnuts or ping pong balls) and gets one more peak into my nose. Result: major septal infection, RTC 3 days to see if my septum perforated. High dose of Keflex and a little pseudophedrine. Not one mention of any cautions about using atbx - especially in a female of child bearing age from her or the pharmacist or mention about the risk for colitis as with all the cephalosporins. She didn't check a system above and below (inside my throat, ears), she didn't even listen to my heart for good measure. So what does all this mean - besides the fact I saved my brain from having an infection spread to it by going to the doctor... it means that providers lose something along the way. As a student we are extra careful in our exams, even as a beginning clinician I suspect we will give a little extra documentation and diligently ask questions and do a stellar physical exam. But when does this honeymoon period of exercising all those great skills we learned from the Great Gietzen or LaBoy end? I hope never. I hope my patients never feel cheated in my time with them or my thoroughness. I know there is a time and place to be quick and a time and place (like in prison) where you can't meet every whim of each patient - but I sincerely hope that my skills that I have learned in both communication and exam and decision making will never falter and compromise my patient care. The 50 y/o pharmacy tech showed more compassion and care and overall customer service in our short meeting than the provider or the MA. What's wrong with health care? So many things have to change and so many of these things won't change depending on who we elect in Nov to reform our failing health care system. I realize how very opinionated I have become regarding health care even more now as a PA student than even as a paramedic (although I have many sentiments about the flaws in that system too). Some of my gripes about health care may seem insignificant, and others may seem biased or crude or even discriminatory, but I haven't come to these conclusions all on my own. I listen to the patients and their complaints (like why are there grossly overweight providers preaching about the need to lose weight or how one patient refused to be treated by anyone on the floor that appeared to be obese.), I am a consumer of health care and I see first hand how I can be a change in the health care system and it drives me to hope that one day I can make more change (like insurance companies not punishing consumers for well checkups - how ridiculous!). I may not be able to change the world, the system or health care as a whole. But I can rest assured knowing that I can provide the best damn health care I can - the kind I would want to be given to me and in knowing I saved my brain today so that I will be around to implement this change.

Fly like paper, get high like planes

I have this song in my head, thanks to my husband. It's probably a good thing I didn't go to clinic today because I doubt any of my patients or the docs would have appreciated my rendition of the song Paper Planes. Yesterday's clinic or rather hospital experience was interesting. One of my brain patients had a moment in the morning where he told everyone to put a gun to their heads and try to fly and it was our fault that the hospital didn't float. A little ativan and oxycodone and he was back to normal and he has no recollection of the event. The other brain patient is making some progress, a capped trach - he's on his way to recovery, it's just a question of how much of a recovery will be made. In the midst of writing my notes, 2 things happened. #1 I found that the resident extern is learning to write a note - this person actually asked me how to write up the ROS. It may just be me, but I thought they taught that in med school. Perhaps not. #2, another patient, not mine, who had been sitting pretty at a HR of 42 all morning decided to have a 15sec period of asystole, then knocked himself back up to the 50s and 60s. Um, pacemaker perhaps? I also rounded on a new admit for another doc, this pt's pretty simple: uncontrolled DM with retinopathy and peripheral neuropathy, partial midfoot amputation of one foot, and a recent horrible trimalleolar fracture of the other with ORIF, she is also on peritoneal dialysis and has a cardiac history. The nephrologist (this cute little old guy) had to come in to teach everyone about peritoneal dialysis - fairly interesting the inter workings. Thankfully I had read up about it shortly before he came in and was able to ask him about the prospect of the Toronto nocturnal heme dialysis being a more viable option for those who failed Peritoneal dialysis but did not care for the inconvenience of heme dialysis. We had an interesting discussion and the other docs slowly walked away from the immediate area - seems they had been pimped by the nephrologist and failed before I happened upon the learning session.

Nothing much else is new. I am slowly preparing myself for my next rotation which will be quite a change from anything else I have done thus far. I am relishing every moment with my husband and the pups knowing the next 6 weeks will fly by all too quickly. Once I leave this time, I don't know when I will be coming home - holidays maybe, but doubtful. KS X 12wks, IA X 6wks, OH X 6wks, then home again for 6wks until I head to Ecuador for the last 6 wks. I am actually having 2nd thoughts about this Ecuador business. Interesting opportunity but just not sure I want to spend the extra money to be so far from home.

Here's a link so you too can have this great little ditty in your head.
http://www.youtube.com/watch?v=7sei-eEjy4g

Task Oriented

So through my short stint of rotations I have found how task oriented I really am and how much I enjoy task oriented jobs. My whole prison rotation was task oriented and thankfully this little stint with Dr. Patomd is sort of task oriented too. Like today for example I had 4 patients to round on and write notes - I did that, gave report and was outta there. Nice. I did have some things to do like figure out why my computer decided to crash when I got home from TX, so it all works out well. It's a nice little break anyway before my trauma rotation which will be busy busy busy, but reminiscent of my paramedic days.

Bored on the floor

Well, I have survived 2 days with Dr. "I hate PAs" and I actually feel bad for calling him that for now, so I will have to think of a new name. He's been ridiculously nice to me. He actually showed genuine concern and (gulp) compassion towards my TX endeavor. He's asked a few questions I didn't quite know, but he didn't make me feel all that stupid for not knowing them. I even heard him crack some jokes today and have some inflections in his otherwise monotone voice. Sure he still throws out info to make him look like a super smart doc and me a lowly stupid PA, but really not as bad as I thought. The PA, well he's God's gift to the PA and medical profession. He threw a few things at me, that I don't know anyone would know unless they just recently read about the EXACT mechanism for prednisone action and its effect in developing PCP. But after answering a few more routine questions, presenting 3 patients and writing some stellar reports he hasn't bothered me much since. In fact, I am completely on my own, rounding on patients and writing notes. My three patients are on autopilot basically but they all have something unique to offer. I got a new Admit that Dr"need a new name" asked me to admit and write an H&P. Talk about the longest note I've written - almost 5 pages. Quick rundown of info of this new pt. under 40 male, PMH of DVT that lead to massive PE, had clot in PFO (patent foramen ovale), ended up having open heart to remove clot and fix PFO - coded with Vfib arrest CPR for 10min, saved, suffered anoxic brain injury and now basically non functioning. He has a trach, PEG tube and likes to pull things out so he's in restraints, he follows commands - some of the time, but completely nonverbal, especially now since we took out his PassyMuir valve on his trach. 22 medications. Probably the most difficult Neuro exam I've ever done - trying to figure out if receptive or expressive aphasia or both or to what extent the damage is. Keeps it interesting.

As I was leaving today, I had a brief conversation with the PA, basically, I am welcome back anytime b/c I have good notes, and have done a good job and been a great help since I came - yesterday. Dr. Patomd (that name will stick for awhile) told me to come back whenever I need to if I need hours b/c "it will keep you out of those clinics which can be really boring" Hmmm, glad I chose not to tell him how bored I was rounding and writing notes - despite the incredibly interesting patients. Oddly enough I miss prison medicine. I wonder how my secondary syphilis guy is doing or how the unknown etiology rashes are and if any of my other mixed pot patients had more interesting pathology.

Oh and in family news - we bought a new (to us) car - a 2006 Jeep cherokee Laredo with 18,000miles. Coincidentally we found out after the purchase (because we were too enamored with the price and mileage and immaculate condition of the car)that it has a V8 and nearly every bell and whistle that possible on that model. Heated seats, mp3 player, trail rated everything! Holy cow! I am so proud of Shawn for working so hard to make it happen and so soon! It's so cool to know that when we have kids, it will be this first car they ride in and will come home strapped in their carseat in the first car we've ever really owned. I feel so grown up.

From one hell to another

I finally escaped TX and the remnants of Hurricane Ike. I am very grateful to be alive and home with my husband. It was much worse than predicted and the area I was staying suffered so much damage, they are still picking up pieces, waiting for everyone to have electricity and only has 1 gas station open, which currently has no gas. Hopefully the raw sewage has been cleaned up too. The gravity of the situation didn't really hit me until I saw the news when I got to Dallas where my mom and grandma met me and then again when I got home and threw my arms around the love of my life, who I was afraid during a couple points through the storm that I may never see him again. Some may accuse me of being melodramatic or over the top about the whole experience, but until you lived through the 100mph winds yourself in the direct path of the hurricane, I beg to differ. I didn't ask to go to TX, I tried to get out but couldn't, and it's not like I am being compensated for my time spent away from my family - infact I paid the school for my TX adventures and paid even more to get an emergency flight out of there. I am so lucky to have a husband, mom, grandma and inlaws that love me so much.
Now that I am back in Portland I now have the luck to be spending the next week with Dr. "I hate PA's" who use to be our medical director (and at one time a PA) but has now moved on to squashing PA-students. Oh joy, can't wait. At least I know I won't lose me life or limb with hell#2.

In joyful news, we're buying a new car soon (new to us anyway) can't wait!!

Another Hurricane

Even though I got let out of clinic early today to evacuate, I find myself sitting at the computer in a house full of people NOT evacuating. I didn't do my presentation (haha) and I didn't get to share my fruit salad - what a waste. I have a flight out of Houston Hobby airport to Amarillo TX (where my mom would get me and take me to KS) but I can't get to the airport. No one will take me and a cab is way too expensive (I just don't have $900 in cash). Stupid Hurricane Ike. I have a stockpile of water in my room, but no boards for my window to ride the storm. I would say about 2/3 of the houses I passed on the way home today were boarding their windows, including the neighbors (the ones not related to us). I was also instructed to stop eating my lunch today because if we lose electricity (and we are more than likely to lose it) there will be no working toilet. But don't worry folks we have x-tra water for drinking stockpiled in an emptied kitty litter container. I feel safe and secure so much in fact I was wishing I had stayed at work and had someone at work swing by my house so I could pick up a suitcase and then they take me to the airport or go home with someone that lives further inland. No matter where it hits, we are on the dirty side. Lucky us. Apparently my family rode out the storm with Rita a few years ago with flooding, roof damage and no electricity. I can't say riding out a hurricane is or was on the top of my lifetime achievements. If I can escape the house tonight I am going to wal-mart for some canned goods and poster board. I am making a sign that says "hi mom, I love you Shawn, and please send me home to the NW." in case I am stuck on the roof of the house after the fact. So look for me on TV I guess. Maybe the storm will fizzle and be nothing, but then again I am not looking forward to the aftermath if it is bad. I may be out of touch and unreachable (and without clean clothes) for a bit.

Nothing new happened in clinic, my one sick call today was a man with hx of GERD/dyspepsia, waiting to get a GI consult in Jan '09. He's also HIV+. He was super gassy, so I gave him an anti-flatulent. Whoo. I did have my most complicated intake I have ever had though, lots of paper work and labs to be ordered: HIV, HTN, TB+ (s/p prophy 9months), SZ disoder, mental illness (thank goodness not my dept), bisexual (in for prostitution - important to know for safety reason, just glad he wasn't on estrogen) and currently on lifetime prophy for PCP. He took an hour.

Each morning I drive to work I try to catch a segment on one of the radio stations call "whatchya doin' at the courthouse" it has a catchy jingle that I found myself singing along with today. And the short bit is exactly what it sounds like. The radio DJ (Sara) asks people why they are there. Some are good, others are stupid and some, well only in Texas I'm sure. Here's a couple stories from today: a man accidentally caught his house on fire, when he poured gasoline in his doorway to keep out a friend of his that he was fighting with. The vapors caught fire from the hallway heating unit. Charge: arson. Next person was charging the police officers who tazed him when he was running from them for use of excessive force. Sara gave him a couple scenarios of would you rather... and here they are: would you rather have to bike to work everyday or be tazed? - ride bike. Would you rather go to jail for 6mo or be tazed - go to jail. would you rather be on the Maury Povich show to see if you are a lady's baby's daddy or be tazed - tazed - in fact you can taze me twice. A woman trying to get child support from her baby's daddy. She was asked how many kids she had - 5, and how many baby's daddy's? 6 (apparently there's one on the way - must be a lucky guy)