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INTP+ 8w5

[gatoncomic]

[populationpensive]

PA Specialty Series: Emergency Medicine

In the inaugural post of the PA Specialty Series, we feature the lovely @digiti-minimi, a PA-C in Emergency Medicine. Learn about a typical day for a PA in the ED, relationships with physicians, and what every PA-s should know before going on rotation in emergency medicine.

Keep reading

[we-need-medicine]

Rotation Recap #1 - Endocrinology (Elective)

So I recently finished up my very first rotation! In my program we get 2 elective rotations, and I picked endo as my first. It was a really great first rotation and I loved every minute! 

I really like @livingthepadream‘s “template” of sorts to recap rotations, so I’m basing mine off that! Thank you!!! :D

What I liked about endo: It was a lot of patient education and interaction, which helped me solidify a lot of useful information about common conditions. It involved a lot of history-taking as well, so I feel very solid on that now. I am also personally interested in the endocrine system, which made it a really engaging experience. 

What I didn’t like about endo: I pretty much saw the same 5 or 6 conditions. About 95% of the patients I saw were routine follow-ups, too, so it really wasn’t a lot of “problem-solving” or investigation, but more so medication adjustments and prevention. 

Favorite things about my site: I actually did this rotation at my own endocrinologist, so it was only 20 minutes from where I live, and I knew a few of the staff there before I started. It was a comforting feeling to have walking into my first rotation! The entire staff I worked with, which included 4 physicians, 2 NPs, 4 MAs, and administrators, were very kind and helpful to me, which made me feel right at home.

Things I didn’t like about my site: The office was really physically small for how much was going on in it (they used to have 2 offices but had to consolidate into 1 due to a previous physician going on medical leave). The NPs didn’t have offices, so they used exam rooms as their offices. It was very cramped when I was working with them! I also had one doctor that didn’t really know what to do with me when I was working with her, so I ended up just doing a lot of shadowing with her. 

Common things I saw: DIABETES! A decent mix of type 1, type 2, and gestational. Hypothyroidism, hyperthyroidism, and thyroid nodules. Post-surgical/post-treatment thyroid cancer patients. We also managed the hypertension and hyperlipidemia of DM patients, so I got a lot of experience with those as well.

Uncommon things I saw: Cushing’s disease/syndrome, congenital adrenal hyperplasia, pituitary adenoma, and MODY. 

Common procedures: In-office HbA1Cs, glucometer readings, subcutaneous injections (insulin!), thyroid ultrasounds, and fine needle aspiration biopsies. I only got to observe with the latter two, but were still very cool to see!

Overall thoughts: I am very glad I got to have this as my first rotation. It was a little more laid back than I imagine some of my future rotations will be, yet it really helped me solidify some very common conditions (DM, hypertension, hyperlipidemia, hypothyroidism) that I will surely see daily when I’m on my family med/internal med rotations (I feel like a DM pro now!). As sad as I was to go, by the end of the rotation, I was itching to see a little more action. I guarantee I will see plenty more on my next rotation starting Tuesday! 

Up Next: Emergency Medicine

[meddaily]

H’s and T’s

Anyone that has dealt with a cardiac patient or taken a ACLS class will know their H’s & T’s. Some of us find it to be just another long list of things to remember out in the field, but when it comes down to it, these are what doctors want medical professionals to know to look for when a pt is having a cardiac emergency.

Hypovolemia Hypothermia Hypoxia H+ Ions Hyper/hypokalemia or glycemia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary.

These ten disorders can easily through the human body out of whack and it’s that simple to cause the person’s heart to disagree with the situation and begin to act up. With that being said, most of these are pretty quick fixes.

Hypovolemia - a loss of fluid, making cardiac output drop. Usually if the pt is CAOx3 and you get a BP of 70/36, you might find them to be running a bit tachy. Some normal saline is a quick fix for people and might help correct the issue.

Hypothermia - pretty self explanatory, but to keep it simple: Warm the person up and you’ll see them kicking

Hypoxia - What makes the heart happy? A good supply of wonderful O2! So, if you are hypoxic the best thing to do is put them on a NRB at 15 lpm (if airway and breath on own), or start bagging them with 15 lpm O2 going.

H+ ions - might seem weird, but it just means acidosis. pH balance is monumental for the body and any shift too far one way or the other and you’re going to have issues. If the pt is acidotic, the two major forms of treatment are bicarb and O2, which varies upon what kind of acidosis they have. (maybe I’ll talk about his in a future lecture)

Hypo/hyperkalemia or glycemia - The major one I will discuss is the K+ levels. Hypokalemia is considered <3.5 mmol/L but you won’t see changes really until about <2.7 mmol/L. Prolong PRi may occure, flat or inverse T waves, ST depression, U waves may occur. You may find SVT or ventricular ectopic beats. A-fib, A-flutter, atrial Tach are all possible as well.

(source: LIFEINTHEFASTLANE)

Tension pneumothorax: Air trapped into the chest cavity. An open chest wound can become a sucking chest wound. People naturally prone to closed Tension pneumos or trauma may cause it. Absent lung sounds on one side, tracheal deviations and JVD may be present for this. Common treatment will be a Needle Chest Decompression in the field and then a chest tube in the hospital.

Tamponade, cardiac: If the pt is unconscious, you probably won’t know this until you get a ultrasound of the pt’s heart. If they are awake, you might find beck’s triad with the pt. For field paramedics, this just means you need to load and go. For hospital the procedure of removing the fluids from the pericardial sac becomes important. This is done by placing a needle catheter into the pleural space and removing the fluid.

JEMS STORY

Toxins: Such a wide variety of toxins can cause cardiac arrest. The major thing to do in this situation is hope that you know what they took and hope even more that you have a reversal agent for it.

Thrombosis: A blockage in the lungs or the coronary arteries is deadly! For the field you won’t know to much other then a possible STEMI on your EKG strip. The cath lab is probably your best chance of find it though.

The major thing to remember is that knowing how to reverse these different issues are key in helping your pts. This means knowing your H’s and T’s will help you narrow down treatments options when you have a cardiac issue. Pay attention not only to the patient but the information you get from them or the family. There just might be some clues hidden in their words.

Remember to follow me at MedDaily and show support for my new project!

[aspiringdoctors-blog]

Basics for the Wards: Reading a Chest X Ray

Chest X-rays (aka CXR) are one of the most basic imaging studies done in medicine. Almost every hospitalized patient has one and you will see hundreds of them by the time you finish med school.

But it was be super easy to get distracted by the huge glaring pathology (like a giant mass) that you miss other pathology (like a broken clavicle). So, like with reading EKGs, it’s best to have an algorithm you run through for every CXR so you don’t miss anything.

Disclaimer: Again, this is just a general introduction with some basics to help you start out on wards. There is a lot more to interpreting chest x-rays that what I mention, that is why radiologists are awesome.

First: What is the view- is it AP (front to back) or PA (back to front)? Lateral CXRs are obvious.

PA

AP

If the patient is able to stand, a PA view is generally preferred. AP is generally when patients are confined to the bed- also you usually cannot diagnose cardiomegaly from an AP view because the heart is almost always bigger in this view. How do you tell the difference between them? Look at the scapula- in a PA view the scapula are usually clear of the lungs, whereas in an AP view the two generally overlap. Sometimes the clavicle positioning can be a good clue too- see the differences between the two?

Lateral

Second- what is the quality, because that can have a major effect on your interpretation. A good mnemonic is RIP.

- Rotation - Measure the distance of each clavicle from the spinous processes at that level, if they are equidistant then the patient is not rotated.

- Inspiration - If you can count nine posterior ribs within the lung fields before you reach the diaphragm, then there was enough inspiratory effort. Poor inspiratory effort will look like the patient has an airspace disease. Note: Posterior ribs = more apparent, look more horizontal. Anterior ribs = less visible, 45ish degree angle towards feet

- Penetration - With flawless penetration, you should be able to see the thoracic spine through the heart.

Underpenetration= Left hemidiaphragm and left lung base will not be visible, and pulmonary markings will appear more prominent than they actually are. Ahhhh!!!!

Overpenetration= what is even happening here

OK, now you’re ready to see what is going on with the patient. I suggest the systematic approach, which has the handy mnemonic ABCDE= airway, bones, cardiac, diaphragm, everything else (lungs). I’m not going to go into all the pathology associated with everything, because that would take forever.

- Airway: Is the trachea patent and midline? Can you see the mainstem bronchi and the carina? If there is an endotracheal tube in place, make sure that it is 3-4 cm above the carina. Also check to make sure the mediastinum is not deviated or abnormally wide.

- Bones: Is anything broken or dislocated? Any lytic lesions? 

- Cardiac: How clear is the cardiac silhouette? Is the heart enlarged? What about all the vessels- the aorta, SVC, IVC, etc. 

- Diaphragm: Is the right side higher than the left but not like wayyyy too much? Are the costophrenic angles clear (if not, could be an effusion!)? 

- Everything else: NOW you can look at the lungs. Is there an infiltrate or a mass? What about pneumothorax? Also check for you friendly neighborhood gastric air bubble, it’s supposed to be below the diaphragm. 

Easy enough, right? Good luck! 

[cranquis]

Allow me to add Step 0.5: Be sure the name on the xray matches the name on your patient before you spend all your time interpreting an image which doesn’t provide you with any useful data… ;)

(I got pimp-shamed on rounds once because of this error – NEVER AGAIN.)

[populationpensive]

Needed to look at my Medical Study Tab to pull up this puppy! Now that we learned how to interpret CXR at school, this comes in handy! Also a more clear version of the approach we were given. 

[we-need-medicine]

Rotation Recap #4: Orthopedic Surgery/Sports Medicine

This is a little late, but I finished up my 4th rotation about a week and a half ago! This was my 2nd elective rotation, which I did in orthopedic surgery and sports medicine. I really enjoyed this rotation, and learned so much more than I expected to. In 5 short weeks I felt like an ortho pro! I had 3 clinic days a week and 2 OR days. Although I have a general surgery rotation to do still, this was my first surgery experience! 

What I liked about ortho: I really enjoyed how focused my practice was. The practice was huge, so each physician focused on their own specialties. The physician and PA I was with were focused on sports injuries, knees, and shoulders. So I learned almost all there is to know about these types of injuries and conditions. I personally like how “definite” ortho diagnoses can be due to so many special physical exam tests and imaging. I also enjoy specialties in that you can go more in-depth with these patient’s issues. 

What I didn’t like about ortho: As I mentioned, the practice is highly specialized. Due to that, I didn’t get to see many patients that had issues with other body parts besides knees and shoulders. I would have loved to see some trauma, spine, neck, and hand patients but I didn’t really get that opportunity. 

Favorite things about my site: The PA and surgeon I worked with were extremely enthusiastic about helping me learn. They were both extremely smart, and they were very easy going and friendly (which is opposite of the stereotype of orthopedic surgeons that I’ve heard!). The PA even had lesson plans set up for me, something I have yet to have gotten from a preceptor. The demographic variety of patients I saw was very wide (I even saw prisoners). Many of the facilities were also extremely nice. The surgeon had two fellows he was teaching at the time on surgery days, and they were also very enthusiastic about teaching me things, even though they had no obligation to. The site was very fast-paced, which I really liked.

Things I didn’t like about my site: On clinic days, I had to travel between offices throughout the day. Often times the offices would be on opposite sides of the city of Pittsburgh! It put a lot of miles on my poor car. 

Common things I saw: Meniscus tears, collateral ligament sprains, ACL tears, osteoarthritis, rotator cuff sprains and tears, knee contusions, patellar subluxations, Bakers cysts, and minor joint effusions.

Uncommon things I saw: Osgood-Schlatters, shoulder dislocations, patellar fracture, tibial fracture, and large (like, 120 cc of aspirate) joint effusions. Common procedures: Joint injections, joint aspirations, brace placements, and suture removal. I also got to first assist in surgery, which consisted of procedures such as suturing, suctioning, extremity maneuvering (sometimes I’d have to hold an arm above my head for 20+ minutes!), ACL graft preparation, and placing sterile dressings.

Overall thoughts: I enjoyed this rotation so much! It really helped me solidify my musculoskeletal physical exam, reading x-rays, gave me some tips on reading MRIs, and made me very confident in the OR, which I’m sure will carry over to my surgery rotation. I got so much out of this rotation and I’m really hoping that someday I can work in an ortho practice as fantastic as this one was. I was really bummed to leave this rotation, but I have already planned to go back for a few OR days during my scheduled breaks from rotations to get some more experience! 

Up Next: Family Medicine

[medicowesome]

COPD: Tips for step 2 CK and rounds

Hello! I have a pulmonary rotation going on and I thought I’d shed light on management of COPD :D During rotations, you may be asked what you want to do for the patient. I have written “Plan” for what you might want to answer to impress your attending. I’ve included a few common brand names too :) Inhalers: Remember inhalers only improve symptoms and have no mortality benefit and do not affect the progression of the disease. For all patients with COPD: A short-acting bronchodilator (eg, beta-agonist, anticholinergic agent) is prescribed for use as-needed for relief of intermittent increases in dyspnea. Plan: Albuterol PRN COPDers in whom intermittent short-acting bronchodilators are insufficient to control symptoms or two or more exacerbations in the previous year: Add a regularly scheduled long-acting inhaled bronchodilator. The long-acting inhaled anticholinergic (muscarinic) agent (LAMA) is preferred to the twice daily long-acting beta agonists (LABAs). Plan: Albuterol PRN Tiotropium OD (Spiriva) Important for step 2 CK: Inhaled anti-cholinergics are the most effective in COPD. (Contrary to asthma, where you start Inhaled steroids if symptoms aren’t controlled by short acting bronchodilator like albuterol alone.) Mnemonic: antiCholinergics are the Coolest in COPD. For patients who continue to have respiratory symptoms or exercise limitations when using long-acting inhaled bronchodilator monotherapy, add a second long-acting bronchodilator from another class (LAMA or LABA), rather than adding an inhaled glucocorticoid. For patients who continue to have symptoms or have repeated exacerbations despite an optimal long-acting inhaled bronchodilator regimen, add an inhaled glucocorticoid (ICS). An inhaled glucocorticoid may be warranted earlier (ie, at the same time that the long-acting inhaled bronchodilator is initiated) if there are signs of inflammation or an asthmatic component to the COPD. Personally, I have seen them prescribed together in clinical practice rather than one after the other. Plan: Albuterol PRN Tiotropium OD Fluticasone / Salmeterol BD (Adavir) Or Budesonide / Formoterol BD (Symbicort) Stuff that has a  mortality benefit: Oxygen therapy Smoking cessation Vaccination (Influenza, pneumococcal) Clinical pearl: Always ask your COPD patient when was their last flu shot. If your attending asks, you’ll know it like a boss B) When do you start O2? Start O2 when pO2 < 55, sat < 88% (Silly question that I asked and answered myself: Why don’t we start O2 right away if it’s so awesomee? Because carrying an O2 cylinder around isn’t always feasible lol.) Other things to shine on rounds: Know that COPD is a systemic disease, not just a lung disease - Depression, osteoporosis, weight loss, etc are also a part of the disease. Read about BODE index. Know about the anti-inflammatory effects of macrolides in COPD exacerbations. That’s all! We rise by lifting others :) -IkaN

[findingmedinspiration]

Thank you

[we-need-medicine]

Rotation Recap #5 - Family Medicine

I know I’ve fallen behind on these (I just started my 7th rotation!) but figured I would recap them anyway, so I’ll post my 6th rotation recap sometime next week.

Anyway, my family medicine rotation was about what I expected it to be. The practice was actually an internal medicine office, so unfortunately I didn’t get to see any pediatrics.  

What I liked about FM: You get to see a little bit of everything and end up seeing patients of all ages. The days were pretty easy and typical, and I was never at the office too late. 

What I didn’t like about FM: Many of the appointments were annual exams, which only really included keeping up with health maintenance and refilling medications. I also did not like that many times when patients had complaints, we had to refer them out for further evaluation, whether it be to a specialist, to get imaging, or labs. 

Favorite things about my site: I was able to brush up some of my knowledge on medications, which I will admit is a weakness of mine, due to reviewing patient’s medication lists constantly. We had drug reps visit every day which also added to this education (and all the free lunches were a bonus, too :P). 

Things I didn’t like about my site:  Many of the patients at this location (a somewhat rural area compared to the rest of my rotations which have been urban/suburban) were against keeping up with health maintenance, such as colonoscopies, vaccinations, and lab work. Some even gave me a hard time suggesting against the suggestions I gave to eat healthier or stop smoking! The office I was at was also incredibly disorganized and messy which was kind of a turn-off, and my preceptor and the doctor working there seemed rather stoic. 

Common things I saw: As this rotation was from February to March, I saw tons of bronchitis, strep throat, sinusitis, and colds. Acute issues I saw included headaches, back pain/strain and sciatica, rashes, and UTIs. Chronic conditions included DM, hypertension, hyperlipidemia, COPD/emphysema, asthma, allergic sinusitis, hypothyroidism, migraines, anxiety, and depression.

Uncommon things I saw: Rotator cuff tendinitis, heart failure exacerbations, tympanic membrane rupture, infected abscesses, and dog bites.

Common procedures: I did not end up performing many procedures here. However, I did get to perform a subacromial injection and assist with two I&Ds of minor abscesses.

Overall thoughts: This rotation was ok, but I do not think I would want a job in primary care. I did get to learn a lot about different medications, but I did not get to do many procedures. So many patient’s issues ended up being referred out, and many patients were there for simple maintenance visits. It was a calm practice and I can see why some people would like to go into primary care, but at this point in my life I find it a bit boring! 

Up Next: Women’s health

[nursingthehudson]

Quick Sheet: Hormones Produced in the endocrine system

Gland

Hormone(s) Produced

Primary Function(s)

Hypothalamus

Regulatory hormones

Control release of hormones from anterior pituitary

Hypothalamus (released from posterior pituitary)

Antidiuretic hormone (ADH)

Stimulates both the kidneys to decrease urine output and thirst center to increase fluid intake when the body is dehydrated; in high doses, ADH is a vasoconstrictor (thus, it is also called vasopressin)

Oxytocin

Contraction of smooth muscle of uterus; ejection of milk; increases feelings of emotional bonding between individuals

Pituitary gland (anterior)

Thyroid-stimulating hormone

Stimulates thyroid gland to release thyroid hormone

Prolactin (PRL)

Regulates mammary gland growth and breast milk production in females; may increase secretion of testosterone in males

Follicle-stimulating hormone (FSH)

Controls development of both oocyte and ovarian follicle (spherical structure that houses an oocyte) within ovaries; controls development of sperm within testes

Luteinizing hormone (LH)

Induces ovulation of secondary oocyte from the ovarian follicle

Controls testosterone synthesis within testes

Adrenocorticotropic hormone (ACTH)

Stimulates adrenal cortex to release corticosteroids (e.g., cortisol)

Growth hormone (GH)

Release of insulin-like growth factors (IGFs) from liver; GH and IGFs function synergistically to induce growth

Pineal gland

Melatonin

Helps regulate the body’s circadian rhythms (biological clock); functions in sexual maturation

Thyroid gland

Thyroid hormones:

T3 (triiodothyronine) and

T4 (tetraiodothyronine or thyroxine)

Increase metabolic rate of all cells; increase heat production (calorigenic effect)

Calcitonin

Decreases blood calcium levels; most significant in children

Parathyroid glands

Parathyroid hormone (PTH)

Increases blood calcium levels by stimulating both release of calcium from bone tissue and decrease loss of calcium in urine; causes formation of calcitriol hormone (a hormone that increases calcium absorption from small intestine)

Thymus

Thymosin, thymulin, thymopoietin

Maturation of T-lymphocytes (a type of white blood cell or leukocyte)

Adrenal cortex

Mineralocorticoids (e.g., aldosterone)

Regulate blood Na+ and K+ levels by decreasing the Na+ and increasing the K+ excreted in urine

Glucocorticoids (e.g., cortisol)

Participate in the stress response; increase nutrients (e.g., glucose) that are available in the blood

Gonadocorticoids (e.g., dehydroepiandrosterone [DHEA])

Stimulate maturation and functioning of reproductive system

Adrenal medulla

Epinephrine (EPI) and norepinephrine (NE)

Prolong effects of the sympathetic division of the autonomic nervous system

Pancreas

Insulin

Decreases blood glucose levels

Glucagon

Increases blood glucose levels

Testes (gonads)

Testosterone

Stimulates maturation and function of male reproductive system

Inhibin

Inhibits release of follicle-stimulating hormone (FSH) from anterior pituitary

Ovaries (gonads)

Estrogen and progesterone

Stimulates maturation and function of female reproductive system

Inhibin

Inhibits release of follicle-stimulating hormone (FSH) from anterior pituitary

Heart

Atrial natriuretic peptide (ANP)

Functions primarily to decrease blood pressure by stimulating both the kidneys to increase urine output and the blood vessels to dilate

Kidneys

Erythropoietin (EPO)

Increases production of red blood cells (erythrocytes)

Liver

Angiotensinogen

Converted by enzymes released from the kidney and within the inner lining of blood vessels to angiotensin II; increases blood pressure by causing vasoconstriction and decreasing urine output; stimulates thirst center

Insulin-like growth factors (IGFs)

Functions synergistically with growth hormone to regulate growth

Erythropoietin (EPO)

Increases production of red blood cells (erythrocytes); note that kidneys are the major producers of EPO

Stomach

Gastrin

Facilitates digestion within stomach

Small intestine

Secretin

Regulates digestion within small intestine by helping to maintain normal pH within small intestine

Cholecystokinin (CCK)

Regulates digestion within small intestine by facilitating digestion of nutrients within small intestine

Skin

Vitamin D3

Converted by enzymes of liver and kidney to calcitriol; functions synergistically with PTH and increases calcium absorption from small intestine

Adipose connective tissue

Leptin

Helps regulate food intake

Placenta

Estrogen and progesterone

Stimulates development of fetus; stimulates physical changes within mother associated with pregnancy including those in the uterus and mammary glands

[medbeyondwords]

Chest X-Rays (CXR) Interpretation

DRSABCD is a familiar acronym for those who have undertaken First Aid/Basic Life Support courses. Now DRSABCDE can used as a simple, yet comprehensive, approach to CXR interpretation.

Normal CXR 

D – Details: 

Patient name, age / DOB, sex

Type of film – PA or AP, erect or supine, correct L/R marker, inspiratory/expiratory series

Date and time of study

R – RIPE (assessing the image quality)

Rotation – medial clavicle ends equidistant from spinous process

Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?

Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)

Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.

S – Soft tissues and bones (it is common to leave it until the end)

Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density

Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses

Breast shadows

Calcification – great vessels, carotids

A – Airway & mediastinum

Trachea – central or slightly to right lung as crosses aortic arch

Paratracheal/mediastinal masses or adenopathy

Carina & RMB/LMB

Mediastinal width <8cm on PA film

Aortic knob

Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.

Check vessels, calcification.

B – Breathing

Lung fields

Pleura: reflections, thickenning

Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices

Pneumothorax – don’t forget apices

Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae

Horizontal fissure on Right Lung

Pulmonary infiltrates – interstitial vs alveolar pattern

Coin lesions

Cavitary lesions

C – Circulation

Heart position –⅔ to left, ⅓ to right

Heart size – measure cardiothoracic ratio on PA film (normal <0.5)

Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

Heart shape

Aortic stripe

D – Diaphragm

Hemidiaphragm levels – Right Lung higher than Left Lung (~2.5cm / 1 intercostal space)

Diaphragm shape/contour

Cardiophrenic and costophrenic angles – clear and sharp

Gastric bubble / colonic air

Subdiaphragmatic air (pneumoperitoneum)

E – Extras

CVP line, NG tube, PA catheters, ECG electrodes, etc

More medical content here!

[we-need-medicine]

Rotation Recap #7 - General Surgery

Alright, I’m well aware this recap is literally months late - that’s my own fault. As I mentioned in a previous post, my last few months in PA school were incredibly hectic with studying for capstone exams and boards! 

My 7th rotation was general surgery. Though it’s common to have a mix of OR days and clinic days on surgery rotations, my rotation was all hospital based. This included OR time, ER consults, and inpatient rounding on pre and post surgical patients. I worked with several PAs as a hospital surgery staff, so we worked with many different surgeons.

I enjoyed this rotation, and I believe it’s the rotation I learned the most on. The days were long, usually spending 55-60 hours a week at the hospital. It was also the only rotation I got inpatient rounding experience on. Since I had 2 rotations with some OR experience before this one, I felt very prepared with OR etiquette. 

Fun fact - I got placed at this rotation the Friday before I was supposed to start. My original surgery rotation fell through somehow so I almost didn’t have a rotation to go to lol. I got very lucky because it was a great experience. 

What I liked about surgery: I very much enjoy doing procedures, and surgery is the place to be to get that procedure experience. It was very different than day to day clinic work. Due to the nature of the day (OR for hours, then rounding and consults the rest of the day), the hours went by very quickly. I was also given a lot of freedom to see patients on the floors on my own, as well as first assisting experience. 

What I didn’t like about surgery: When working with general surgeons, we seemed to always seem the same variety of cases. I also grew to dislike how many hours I was spending at the hospital, as it left me with hardly any time to study for my EOR exam and PACKRAT, which we had to take at the end of this rotation. 

Favorite things about my site: The hospital was a brand new hospital, so everything was state of the art and had a bright feel to it. The PAs I worked with were mostly all nice and made sure we were learning as much as possible. Though most of the surgeons we worked with were general surgeons, we also got some experience with other types of surgery too, including vascular, neurologic, plastics, and thyroid.

Things I didn’t like about my site: One of the PAs on the surgical staff was really a downer and always skipped out on rounding patients, which made the days longer because we had to pick up her slack. I also got pimped the most BY FAR on this rotation, and while the questions were usually fair, sometimes I felt the questions were really tough (one surgeon asked us to calculate different max lidocaine doses while we were scrubbed in, so we couldn’t use any calculators like we would totally be able to in real life!)

Common things I saw: Appendicitis, SBOs, diverticulitis, cholecystitis, cholelithiasis/choledocholithiasis, spinal cord stimulator implants, carpal tunnel releases, chemo pump insertions, temporal artery biopsies, lipoma removals, and parathyroidectomies. 

Uncommon things I saw: Cholangitis, tissue debridements of pressure ulcers, thyroid nodule removals, reversal of colectomies with stomas, a gynecomastia reduction, a tummy tuck, and a 13 cm wide AAA that was found incidentally on CT. 

Common procedures: In addition to the surgeries listed above, we performed a lot of NG tube insertions and removals and surgical drain removals. 

Overall thoughts: I worked my ass off on this rotation, but I ended up enjoying my time there, and as I mentioned earlier, it was the best learning experience of all my rotations. Though I’m unsure that I would ever go into general surgery specifically, I like the surgical setting a lot!

Up Next: Pediatric emergency medicine

[we-need-medicine]

Rotation Recap #8 - Pediatrics (EM)

My final rotation was in a pediatric emergency department - where I got my first job! 

I’m really glad I finished out PA school with this rotation for many reasons as I describe below. By this rotation, I felt super confident in everything I was doing and it truly felt like the home stretch.

At this rotation, PA students were utilized like residents. I had a ton of freedom - I would pick a patient to see, then precept them to the attending physician (after tracking them down - they were always so busy) of that “pod”. The attending would then see the patient his or herself, then we’d discuss a plan together. I’d then write the entire note while the attending put in orders, then rinse and repeat. 

What I liked about PEM: Going into PA school, I really didn’t feel strongly one way or another about working with kids. But after my general EM rotation, I figured I would enjoy this rotation because I LOVED EM. For the most part, kids a really fun to work with, and many are legitimate about their complaints (AKA, no pain med seekers or idiot drunks). As I mentioned in a previous post, I like EM a lot due to the wide variety of things seen every day. 

What I didn’t like about PEM: At this site, I could tell some of the attending physicians weren’t too happy about having to work with PA students. One attending told me that when letting a PA student work with them, that attending has to go into it realizing that it will be more work for them on that shift, and some just aren’t OK with that. Therefore, I had a handful that simply would tell me to simply shadow a resident my whole shift. This ED is also very heavy on teaching, so there were many other PA students and residents floating around, so things could get hectic and I often felt lost in the shuffle. 

Favorite things about my site: I really enjoyed the amount of freedom I had. It gave me a good vibe for how life would be as a PA-C, which is why it was the perfect final rotation. The children’s hospital had such an upbeat vibe, and everyone I came in contact with there was very friendly and helpful. The shifts I was on were great, too - I only had 3 or 4 shifts a week, always 8 hours, either 10a-6p or 5p-1a. 

Things I didn’t like about my site: As a student, we were only allowed to work in the yellow and orange pods (severity ranged from red to blue/fast track), so I did not get any experience with extremely emergent cases or with fast track-like patients. We were also required to park about a mile away from the hospital and take a shuttle in, due to lack of space in the parking garage (it’s a very urban setting with little space). Many of the patients with odd or really hands-on complaints (like lacs or splint applications) were saved for residents to see so I was kind of left in the dust in that aspect.

Common things I saw: Gastroenteritis, URIs, asthma exacerbations, pneumonia, syncope, lacerations, dehydration, headaches, constipation, CHIs, corneal abrasions, strep throat, AOM, and lots of ortho injuries including sprains, fractures, subluxations, and dislocations.

Uncommon things I saw: Appendicitis, cholelithiasis, MVAs, foreign bodies, near drowning, new onset OCD, anxiety attacks, hot tub folliculitis, lice, PID, animal bites, abscesses, and abuse cases. 

Common procedures: Splint application, foreign body removal, laceration repair, fluorescein staining, and I&Ds. 

Overall thoughts: Clearly I loved this rotation, because I took a job there! I think it was best as a final rotation and I may not have liked it as much had I been placed there earlier on in my clinical year. But I can’t wait to see what else the PEM has in store for me!

[garden-of-everything]

medical field stereotypes

Family Medicine - personality: easy-going, family-oriented - quirk: low self-esteem - 7 deadly sin: gluttony - hobbies: hanging out with your significant other and other family medicine docs

Internal Medicine - personality: ambitious, jack-of-all-trades - quirk: over-confident - 7 deadly sin: pride - hobbies: cooking, moderate physical activity

Pediatrics - personality: patient, childlike - quirk: eccentric - 7 deadly sin: gluttony - hobbies: maintains “childish hobbies”, love of Disney, music, and games

General Surgery - personality: daring, high-achiever - quirk: narcissistic - 7 deadly sin: pride - hobbies: secretly slovenly at home, loves going and eating out

Ob-Gyn - personality: well-rounded, grounded - quirk: catty - 7 deadly sin: pride - hobbies: your children > your spouse, always doing or planning something

Psychiatry - personality: loquacious, social - quirk: diva - 7 deadly sin: envy - hobbies: going out to town, having people over, selfies and social media

Emergency Medicine - personality: confident, outgoing - quirk: impatient - 7 deadly sin: lust - hobbies: working out/aggressive physical activity, teaching

Neurology - personality: efficient, organized, quiet - quirk: odd - 7 deadly sin: pride - hobbies: the kinds that can be done alone like reading or gardening or raising goats

Radiology - personality: down-to-earth, eloquent - quirk: self-centered - 7 deadly sins: lust - hobbies: travel, fine dining

[snowandstarlight]

Part 1: A Day in the Life of a Surgical Intern (according to Grey’s Anatomy)

7:00am: wake up. the sun is shining, you spend a while lounging in bed with your aesthetically pleasing significant other/co-worker before going down to the kitchen to have a full balanced breakfast with your fellow residents

8:00am: arrive at the hospital and change into scrubs in your co-ed locker room. someone says ‘hurry or we’ll be late for pre-rounds’

8:30am: rounds with every surgical intern in the hospital, the single resident, and maybe the attending for each patient. there is one patient on every service, which is good because there’s only one attending per service. residents are assigned to cases based on whoever can answer questions about the patient and/or procedure

9:00am: cases start. interns not operating sit in the gallery to watch surgeries while snacking/practicing sutures/studying. sometimes they get paged for things like incoming traumas, or catastrophes related to the one patient they are each assigned

12:00pm: everyone is free for a long lunch in the cafeteria

1:00pm: incoming trauma. the ED is run by surgeons, and the trauma rooms are a free-for-all. sometimes these go to the OR, often staffed by half the attendings in the hospital

2:00pm: interns not scrubbed in take a break from their busy schedules to sit in the hallway and stress about their future careers plus/minus their love lives

4:00pm: cases are usually done for the day. attendings and/or residents break the good or bad news to their patients’ families.

5:00pm: end of the day gathering in the locker room

6:00pm: everyone goes to the bar across the street and gets wasted, since they don’t have to work until the sun rises the next morning. sometimes this is a date. once in a while people go on dates to other places, for the novelty. 

12:00am: after hours of drinking +/- relationship conversations, everyone goes to bed

[dxmedstudent]

(if we’re talking about medical dramas in general), then you forgot the in-hospital nookie and constant life drama at work. I swear, whenever I catch a bit of any medical drama, it seems like 99% of their working day is taken up with sex, arguments and occasionally saving a dying patient dramatically.

[eclipperton]

The other day when I was running to the call room after getting a stat booty call page I accidentally tripped and fell into the defibrillator and shocked someone in vfib arrest and saved their life ZOINKS

[dxmedstudent]

Stat booty call page!  OMGLemme guess, was this playing in the background? * Why doesn’t my bleep get those calls? I only get the standard cardiac arrests :(  If only defibrillating was that successful. Honestly. TV CPR is even less realistic than TV doctor sex lives (they get to have sex!? Without scheduling it in a diary ?! What BS is this?), and both seem a lot more successful on TV than in reality! About the only thing that is underrepresented is the number of times drunk patients propose to you. * I was talking to a middle aged consultant the other day, who, I kid you not, uses ‘Dontcha’ by the Pussycat dolls as their ringtone. So, y’know, anything is possible.

[snowandstarlight]

i don’t know, I think there are many things that are underrepresented in medical dramas. among them:

- charting

- what 5am actually looks like (and what most people actually look like at 5am)

- getting pages for things like “you wrote hold parameters for this medication and we’re following them, just thought you should know” instead of like, oh no your patient is dying

- on that same subject, getting paged and then no one answering the phone when you call back . really brings that adrenaline rush to a dead stop

- how many of our meals are stolen graham crackers and peanut butter from the patient food cabinet

[snowandstarlight]

PGY-2 According to Grey’s Anatomy

aka commentary on 4x1 that no one cares about from a soon-to-be PGY-2

- apparently second year residents get assigned a group of interns to be in charge of for the year? (which I guess means that Dr. Bailey was supposed to be a second year resident… who is now a senior resident. But NOT chief resident. somehow. I won’t complain about this again I swear.)

- “how was your vacation?” I’m sorry, vacation?? there’s a vacation? who does all the work in the hospital when the residents are on vacation??

(I want a vacation. Can we institute a system where for one week–okay, long weekend–we leave the attendings to their own devices and get a break?)

- to be fair, how Izzie feels about her interns is how I feel with med students. not quite experienced enough to teach them anything. don’t know what to do with them half the time. hopefully as a second year when I’m not writing notes and fielding pages this will be better    

- wait why is anyone paging the chief (sorry, “senior”) resident? they don’t have pagers, just call their cellphone

- calm down Lexie, you went to med school, you 100% delivered a baby (okay, yeah, it’s still cool)

- that’s not how residency works! if you matched at Mass Gen you would actually have to go there, at least for a year until you could transfer

- one thing that actually does happen in real life is attendings visiting each other in the OR. it’s not usually to corner them into personal conversations though. it’s just to say hi and see if something cool is happening. 

- speaking of, Bailey is a resident. she still needs an attending, at least to time her out. since the chief is currently the only general surgeon every shown on screen, presumably he had already been there at the beginning of that case

- man I miss seeing people with their families in the hospital. screw you, COVID

- oh my god you are surgical residents there is almost no reason you would be delivering a baby (although this show seems to think that OB/Gyn is a random rotation for the lame surgeons, for some reason. nope, completely different field, that just also happens to do surgery.)

- what does reverse T have to do with delivering babies?

- unrelated to PGY-2 but the George/Izzie storyline is my least favorite thing about this entire show, and I think the reason I never watched beyond season 3 when it first aired. they have negative chemistry. and I really loved them as friends!

[chaosophia218]

Anatomical studies and drawings by Leonardo da Vinci.

[gnossienne]

how can i be so intelligent like you? i wish i could be more intellectual, interesting.. but i’m not. i don’t know anything about art. what can you say about it?

Shall I tell you something? I am becoming exceedingly tired of these sorts of questions (of which I seem to receive several variants every week). While I naturally preen in the flattery, the question inevitably amounts to an utterly useless exercise in self-deprecation. I’ve seen similar questions posed and answered (bewilderingly unironically!) on other blogs, and I can barely refrain from rolling my eyes into an alternate dimension upon seeing these (“How do you make yourself seem more cultured?”, really?). It seems to stem from an underlying desire to appear interesting by virtue of a shared sycophantic adherence to a certain romanticised ‘aesthetic’ linked to The Secret History and similarly-themed novels (which, rather pointedly, is a darkly ironic deconstruction of pretentiousness; a point which appears to be lost on most of its readers). If you must ask how to be intellectual or interesting, you have already failed in achieving either. Being an intellectual does not automatically make one more interesting, nor does being interesting make one an intellectual. Interest in classics, languages, and obscure media ought to be pursued for genuine interest, not a vacuous series of steps on the ladder to becoming ‘interesting’*. I loathe the idea that the accumulation of certain artistic and cultural affectations magically makes one ‘cultured’. Ticking off criteria on the road to an arbitrary ideal of ‘cultured’ is not cultured at all. In fact, it is completely anathema to it, it is servile superficiality. Being esoteric for the sake of being esoteric is an inane conceit, and the worst form of self-indulgent posturing that there is. Stop looking up ‘how to be more cultured’ and actually find things that interest you. Read Homer if you like, but don’t continue reading it if you don’t like it simply for the sake of fear of not being aligned with an arbitrary ‘aesthetic’. Like what you like unequivocally and without shame. Stop focussing on what constitutes an ‘interesting’ person and simply pursue things that interest you. If you don’t know anything about art, start by reading about it. You are likely still young, so there is time yet, and instead of being made to feel insufficient by aspirational moodboards on the internet, think for yourself. Authenticity is in alarmingly short supply, so don’t contribute further to it by asking such preposterous questions.*Also, please disabuse yourself of the notion that knowledge of primarily Western-centric canon and ideology constitutes being ‘cultured’; for instance, Rabindranath Tagore was more exceptional than Shakespeare could ever hope of being.