All Down Hill From Here

As I walk back and forth packing for my clinical rotations I can't help but ponder about life: family, this last year and a half of didactics and what my future holds. I certainly have mixed feelings swarming my head and heart. 

Last December I wrapped up the 'Prison' portion of PA school, which reminded me of William Wallace yelling, "Freedom." The classroom with no windows, the break room with no windows, fighting the undergrads for quiet spots in the library and being frustrated with the small gym and lack of equipment are just a few of the things I won't miss. I would include tests within this list, but this next 11 months will incorporate such things, especially as we prepare for our certification test: PANCE. 

To give you an idea what this next 11 months will be like, 10 four week rotations and a test specific to our rotation every 8 weeks.  Most of which are in the state of Virginia, but some are out.  We will have: 

2 Internal Medicine

2 Family Medicine

OBGYN

ER

Behavioral Medicine

Pediatrics

Surgery

Elective

I have chosen my elective in Orthopedics.  I feel the most comfortable here, but I also hope to find a job in Ortho. On the other hand, I am keeping my options open.

My first rotation is in Colonial Heights with a hospitalist for Internal Med.  My proctor is originally from Nigeria and has an extremely thick accent, which made it difficult to speak to him over the phone. I know this will be good for me because his accent will make me pay attention and be more thorough, especially since Internal medicine is known to be the more difficult due to the fact it encompasses every aspect of medicine. 

Being under a hospitalist I expect to be on rounds in the early and late hours, see patients at the doctor's own clinic and learn how to admit and discharge individuals. Also, I have been reviewing the pulmonary, cardiac and abdominal exams. I will most likely see a number of individuals with COPD, ischemic cardiac conditions and coronary artery disease. I'll need to incorporate all lab values and other exams.  I hope to be able to practice sutures as well. 

My second rotation is Internal medicine as well, but it's located in Fredericksburg with a different doctor.  One interesting point is that he has a JMU/PA alumni working for him. It will be nice to work closely with someone who has been through the same program. 

Third is Behavioral med back in Harrisonburg.  With the previous two rotations I had to find places to live and I plan on coming home on the weekends to see my family.  However, this third rotation is going to be nice for I get to live at home.  

Below is a quick catch up on our latest adventures on the East coast.  These incorporate both Thanksgiving and Christmas break. 

These first handful of pictures are from Outer Banks, NC. It was extremely cold hence the coats on the beach. I have always wanted to see a lighthouse. 

The lighthouse used to be near where we are standing, but due to preservation purposes it was moved back. 

This pic of Hannah is from Roanoke Island.  From the Croatoan area. 

This huge Christmas tree and train are at the Short Pump mall.

Just showing off her awesomely huge shell.  BTW, she dropped it, shattering it just shortly after this picture, which equals one sad little girl.   

During the Christmas break we took a trip down through NC, SC, GA and then back up into KT and  to VA. We hit up a couple of kid discovery zones.  One being the Lego Land Discovery place, which the girls absolutely loved.

This pic is a rare gem, to get all three of them looking at the camera at the same time.

This Discovery Center in Charlotte was awesome! The facility included a small aquarium (the jellyfish below), snakes you could pet, two stories of hands-on activities, building blocks (some kids were creating structures taller than their parents), a gross bug/smelling zone.  Here the kids learned why bugs and animals eat, poop and smell.  It was rather comical. 

Of course a rainforest was found within the Discovery building. 

Yes, these buildings are built out of Lego.  The Lego Land Discovery Center, a huge place within a mall in Atlanta. (Where was this when I was a kid, SERIOUSLY!)  It had a couple of rides, a 4D lego movie, a ton of area to build lego.  Also, it had a scheduled lego creation class. 

This last picture is a favorite of mine.  Knowing how cold and miserable Knoxville was, these two just played and didn't care about anything else. 

Pig's Feet

So much has transpired since I last posted.  Hopefully, I can sum it up okay.  

Starting with I & D.  Incision and drainage.  One of the annual lecturers brought pig's feet to class.  He had previously implanted a home made oatmealish substance and injected it under the skin. This made the foot look rather edematous. We then practice local anesthesia blockade techniques, such as 'round' and 'square.'  This is the initial 'poke' and 'burn' that patients will feel prior to becoming numb.  Another technique that many physicians use is a 'pinwheel' style (there are other names for it as well,) the needle is inserted into the skin, give a little lidocaine (most common local anesthetic used, but there are others)  to create a wheal and while the needle is still under the skin proceed to go in a circle.  In and out, injecting medicine, but never completely withdrawing the needle. Any technique should work as long as you overlap the previous dose. 

Side note: Some physicians don't even numb up their patients for such procedures.  Another reason to do this is for major hang nails, ya he showed us a video on how to remove one.  That kinda wigged me out a bit. 

Providing time for the numbing effect to kick in, with a 10 blade, puncture the center of the nodule or papule.  The technique we were taught was to cut away first to prevent any pus spray in our direction. Now, once the full length has been cut, time to squeeze.  You got it, all that pus has to be extracted. 

I won't go into anymore detail, I believe you have the idea.  The doctor leading the class showed us some videos on how to perform all the proper techniques.  One included draining a pus-filled pocket in the oropharynx, just superior to the tonsils. Crazy!

Let me continue with the pigs feet stories: 

These friendly feet were our practice buddies for suture class!  O, yeah!  

We had purchased suture practice kits and had be attempting our knot tying skills prior to the course.  With a rope, none the less. 

 The kit provided a CD filled with step-by-step videos, which were extremely helpful.  It taught us two-handed and then one handed styles. This is a one handed square knot repeated.  It then taught how to perform the same knot by way of instruments.  My personal opinion, it's much easier and quicker.  

We, as a class spent a Saturday morning and with the help from local proctors, we lacerated the pig's feet and sutured them up. 

It was a great class, but I forgot to snap a shot of all my fancy work afterwards.  We practiced subcutaneous, continuous and interrupted suturing. There is certainly an art to it.  How and where to place sutures is depended upon the location of the laceration and depth. 

 It reminded me of scouts, practicing the knots repeatedly, just over and over (Thank you to all of who pushed me to obtain the Eagle Scout award.)  Also, the more I can get my hands on instruments, I more comfortable I feel.  I am definitely a 'hands-on' type of student. 

More 'hands-on' courses: 

This was a quick skills class on joint injections, say for steroid injections.  Also, here I am attempting a subpatellar arthrocentesis. If a patient has fluid build up within there joint, it can be removed and then cultured for possible infection. (I know I don't have any gloves on…oops!)

One last skills class we did was FAST.  Focused Assessment with Sonography for Trauma.  A local ER doctor came to educate us on how to perform an quick abdominal scan, including the heart and the bladder with use of ultrasound. 

(Sorry if the video doesn't work properly!)  The video is a transthoracic echocardiogram of my heart.  It's not one of the normal studies done in a FAST exam, but it was fun to do.  (You can see the left atrium and ventricle, including the mitral valve rather well.  Also, the aortic valves leading into the ascending aorta.  The right ventricle is noticeable, but don't as well.)

The major point of the FAST exam is to look for any fluid.  For example, fluid may become stasis between the right kidney and the liver:

Of such is mine.  It takes awhile getting use to the odd-ultrasound images, but once you know what you're looking for it becomes relative easy. (The liver is the left of the screen.  Look for the upper black area, which is a rib shadow and then follow it to the right. You'll see a small, porous object, then a line and then that odd shaped-oval at an angle is the kidney.)

One last one:  Splinting.  

This was a fun class.  I use to work in some Insta-care facilities back in UT and I was able to perform most of these splints already.  However, I just never got familiar with the names and the reasoning.  Now I know. 

Another Catch Up Post

Daylight savings time is giving me an extra hour in the day to get caught on the necessities. One being this blog.  

So, this happened! Dec. 13th is the end of the semester and the end of our didactic year! Woot Woot!

It also means that I have only a few days to get my thesis project wrapped up. The subject upon which I am researching is, non-invasive diagnostic tools for prostate cancer.  I originally proceeded with the inconsistent methods for screening prostate cancer, but I felt like the US Preventative Task Force and the Urology Association had already hounded it to bits, like beating a dead horse.    

In short, too many physicians are relying on the prostate biopsy (TRUS/biopsy), which is determined by PSA (prostate specific antigen).  Two controversial principles: 1) Only 30 - 40% of the biopsies show true positives and it leaves a man feeling worse than when they came in.  In fact, they get bloody urine (hematuria), bloody sperm (hemaspermia) and possible UTI or other bacterial infections. 2) PSA levels…Too many false positives.  So, who is to say biopsies should be based off them…Anyways, I'm looking into EndoMRI, MRI pelvis images and urinal biomarkers vs prostate biopsy. I have to present this to the class and turn in a paper on it the week after Thanksgiving. 

 Last semester, we went down to Charlottesville to perform a male genitourinary exam.  Well, this last month we went back to practice a female genitourinary exam. The only real awkward part was the fact that she was mid-stream menses…yep, oh and the hairy armpits and legs.

The local hospital provided a surgery day for us.  They taught us how to properly wash our hands/forearms for the 5 minute rule and then, how to properly wear sterile technique.  Not only that, but they showed us basics on stitching and use of laproscopic utensils. 

It was neat to see the other side of the operation room.  I have been in the OR a few hundred times, but I had never gotten dressed in the sterile 'blues' before. 

We have also started learning how to perform sutures.  Practicing with a rope, just like scouts. 

In two weeks, we will a class specific to suturing. I'm pretty excited about it. 

This last week, I went to the local free clinic for a great clinical experience. My patient came in for a follow up for recently prescribed hypertension medicine and a colonoscopy referral. As I was reading through his medical record, I found that he was diagnosed with narcolepsy 7 years ago. An extremely rare case. And, supposedly his vehicle was broken into and his Adderall was stolen…ya, right!  Anyways, this is a Schedule II drug.  In other words, this can be a major abusive substance. It is along the same line as Cocaine and Morphine. Anyways, the rule at the clinic is that only one prescription of such potentancy per 30 days. Though, I do feel rather proud having written him a prescription for such a dangerous drug.  

After doing a full cardiac exam, I then did a pulmonary exam and found that he had a right lower lobectomy. Also, we did an EKG.  He had a biphasic wave in lead II and a possible early Right Bundle Branch Block.  Otherwise, he had normal sinus rhythm. 

Last couple of items: The fall season here on the east coast: 

My beautiful girls! This is a place called, "At Home, On the Farm." We were able to pick our own pumpkins.  Granted, this was the first year I didn't carve one cuz I was extremely busy with school.

Fall Colors!!!

 

ER stands for East Rockingham

When I first read the letters 'ER,' I thought for sure I was going to do an observation in the emergency room.  My hope was quickly crushed when I learned ER stands for East Rockingham, which is a local clinic.  Though my hope was slammed down, it was quickly raised as I found that one of my friends is a doctor there.

I showed up at 0800 or just a bit before.  In fact, I arrived prior to my professor (who is a practicing PA at ER.), which is a good thing.  My philosophy, I would rather wait for my proctor than have them waiting for me. So, after a quick tour of the place, (It's actually is a pretty neat lil' facility.  Having your typical radiology, phlebotomy, general practice docs and the orthopedist stopping in twice a week.) we took a look at the schedule and realized our first patient had checked in.  A 50ish yo/m (year old/male) complaining of possible Chigger bites.  With all are patients that day, I had the opportunity of seeing them first.

After entering his room and introducing myself, I gathered a thorough history.  With regards to dermatologic disorders, gathering a history is one of the major key points in diagnosis. He spoke of how the itching and bites had progressed from his feet and ankles superiorly.  He exposed his orange spotted socks.  Seriously, the orange pus filled vesicles had ruptured, spilling its slightly viscous contents onto his white socks.

Another point for dermatology, expose all the skin.  Yep, you got it, this gentleman had bites and pruritus in his grown and perineal region.

Google always provides great imagery:

After presenting it to my proctor/professor we set him up with some tapered Prednisone and other over the counter (OTC) anti-itch stuff.

The next patients I saw was a 50ish yo grandma with her 4 yo granddaughter. G-ma not only came in for a follow up from her previous chest x-ray (CXR) and pneumonia (PNA), but she complained of post nasal drip and congestion.  Diagnosed her with sinusitis and her granddaughter with an upper respiratory infection (URI).

Here is one thing in which I struggle with, the proctor wrote out a script (prescription) for the 4 yo and I   felt that she didn't need anything.  In fact, it was a typical cold that was traveling around. (The granddaughter had an occasional non-productive cough, no rhinitis and was running around the room. I know at night she would present with more symptoms, but...)  My 3 yo had it not just a week prior.  Anyways, I asked my professor about this and she stated that the prescription was just to please the patient. So, how often does a doctor write out a script just to appease their patients? I know it doesn't cost the individuals any until they purchase it from the pharmacy, but we as providers are just handing out drugs like their candy?!  This principle of efficacy will forever remain in the medical field and with hopes that providers will use their best judgement and evidence based studies in making the morally correct decisions. (I know not every physician is just handing out meds.)

East Rockingham provided some great experiences.  These 'hands-on' events provide the best learning environment for me.  

Rhythm

I lost count of the weeks not because of the busy nature of the semester, but more from doing my best to stay on top of things before it over throws me.

I have been debating on what to type lately cuz we have been repeating the same grad-school patterns over and over.  However, while sitting in my Clinical Lab II class our professor handed out a packet.  Not that I'm excited about this by any means.  Unavoidable non the less, the huge EKG test. I was having a perfectly good morning up to that point.  She called out my name and I slowly raised my hand to receive the weighted present.  This test incorporates approximately 20 different EKGs, including limb and 12 lead. We have to not only tell what time of pattern we see, but the rate, rhythm and why.

This was one subject that has brought fear into my life for a while now.  Fact is, I have never dealt with EKGs.  However, having spent the last few weeks going over them I feel much more confident. We began from the basics, reviewed the cardio-physiology, including cardiac output and electrical pathways and then connected the dots. We have an amazing professor who is willing to beat a 'dead horse.'  In other words, repetition on the subject of EKGs was extremely helpful.  The more you look at them, the better you'll get.

On top of this EKG test, we also have an EKG online quiz due the same day.  Also, we took our first Pharmacology II exam today. Not that it went poorly, but it's frustrating to study almost 50 pages ofDETAILED notes and to have only 35 questions, plus some matching of brand/generics on the test. Basically, you put in hours on top of hours of studying just to spit it all out in 20 - 30 minutes. Comparison to a meal, except the food is much more amazing than a test.

As I mentioned previously, we have 1st year student on board now.  It has been interesting to watch their emotional levels rise and fall over the pass couple of weeks.  Especially, during this last week where they took their first tests.  As much as I enjoyed Anatomy and working on the cadavers, I don't believe I could ever do it again.  A couple of us went into the lab to visit with the first years and 'holy crap!' I forgot how awful that smell was!  Anyways, I took some time and covered the radiographs with them and then quickly left.  

Week 1 of 4th Semester!

Can I just take a moment to express my excitement? Not only have I made it passed the first year mark, but now it's my turn to have buddies.  Here's the deal, our PA program has a 'buddy' system providing a soothing transition for the newbies. The president of the 2nd years will look over the list of the in-coming students and matche us with one. In fact, JMU/PA now accepts 30 new students unlike the previous years of 25ish. Because of the extra students I took on two 'buddies.'  

Talk about perspective, "So, that's how I looked my first week of PA school?!"

Bright eyes filled with hope! 

It truly is a different view, knowing they have to experience what I just went through for the past year.  Empathy!  Nothing, but empathy! You know they just signed on and paid thousands of dollar for  professors to knock them on their back and kick 'em while their down. No, for real though, I am here to assist them while they make their transition.  

This semester for us is going to be just as demanding as the last.  However, they are slowly letting us rats out of our cages.  Less lectures and more hands-on work shops!!! Yay!! Our new program director has experience in ER, orthopedics and the OR. He is using his connections to create new workshops for us.  For instance, we will be going to the local ER on a Saturday to learn FAST.  Focused Assessment Sonography in Trauma. This semester we will be learning sutures, splints, foley catheters and joint aspirations.  All of which I am excited for.  

More exciting stuff: EKGs and radiographs.  We are learning how to read such subjects.  EKGs, yes!  However, I'm a bit more enthused for x-rays.  In radiologic technology school I learned how to take images, but not how to intrepid them.  Granted, after working in the field for a number of years I picked some info up, but this will be more detailed. 

I also started a clinic problem solving class.  This is all 'how to' present patient information. Practicing for rounds.  Speaking of rounds, I will know what rotations I will have by the end of this semester.  Rotations start mid January!!!

The least favorite class of this semester is the Women's Med. Don't get me wrong, I'm curious about it, but doubt I'll end up in this field. Can't leave out Pharmacology II and the grad thesis project.

Either way, I'm extremely excited for this semester!

Catch up on summer

After two different planes and five hours of limited leg room, I landed in Idaho Falls where my wonderful wife picked me up.  She and our girls had been in Idaho for the passed three weeks.  After a warm 'hello' we drove 40 minutes to Rexburg where a tent in the back yard awaited us. Did I mention that it was 1230 at night.  However, for my brain it was 230 in the morning!

The next morning we hiked the 'R' mountain, which is an old, benign volcano.  And within a short period of time my lungs were screaming at me.  They had adapted to the lower altitude of Virginia and had a rude awaking.  

Anyways, we had a great time with Abby's family.  We went canoeing, hiking and the kids were able to watch a movie outside by way of projector. They also made shirts with paint and stencils, but of course they had tons of fun with the cousins! Can't forget the great food and company!  

We also had family pictures.

The following week, my family had a nice family reunion at a local park.  It was great seeing everyone and get caught up on life.  I love my family. 

We also did a quick day trip to Utah to visit some friends.  It was great to get caught up with them. We have some many great people in our lives and I'm sad that we didn't have time visit them all. 

The rest of summer was rather restful.  I didn't think about school, didn't touch a book/nothing! In fact, I did everything possible to spend as much time with my family. 

Here it is, time to hit the books yet again.  This will be my fourth semester in the PA program. This semester we will have a bit less in the lectures, which I am greatful for and more of the problem solving and presentations. We have a master's thesis to complete as well. I have chosen my subject as diagnosing prostate cancer: should asymptomatic patients be test vs symptomatic.  I'll go into a few more details later.  A clinical lab class, we will be learning how to read EKGs and X-rays.  More pharmacology and clinical medicine (diseases and disorders). Anyways, I look forward to this semester and pray that we may find success!