Well, here we are.... Nearing the end of my clinical year and coming fast upon graduation. Four months..... 123 days, 16 hours, and 39 minutes - but who's counting, right?
The biggest things going on at present are that I am trying to get a job. I have some prospects, which is very exciting considering the small area in which I had been looking. We come from two small communities and the area employs a total of 29 PAs in 2010. In 2009 the area employed 28 PAs - not a lot of growth over the past couple of years. Thus, not a lot of job openings. That's just fine. I have an opportunity with a local practice and negotiations are underway. I have secret hopes that more opportunities will come along (not that the one I have is poor) but I'm not holding my breath. We are blessed.
The other thing that has been a big change is that my wife is picking up her practice again - she owns a home based business doing landscape design. It has been a busy time for us, but seeing her apply her expertise and skill to beautifying peoples' homes and their land has been delightful. She took a hiatus for a year-and-a-half in order to support me through PA school. The sacrifices she has made have covered every area of our lives, and I am very grateful that she is able to re-institute one of the things she has always enjoyed. She is an expert in my opinion (admittedly, I am biased) and seeing her talents displayed permanently around town has been pleasant, to say the least. I am also glad to think that her sacrifices, as well as mine, will be coming to fruition very soon. Again, we are blessed.
So, where to next? I will be heading to an Indian Health Services Clinic in a very rural town. This promises to be an outstanding rotation, though the commute will a bit killer. I will be able to work in the quick care, pediatric clinic, and diabetes clinic each week. The providers I will be training under have many decades of experience, so there will be much knowledge I can gain from them. This is my final rotation - it will span the next four months and will culminate in graduation.
Six words: I cannot wait til the end.
Saturday, April 23, 2011
Sunday, April 17, 2011
Sick vs. Sick-sick
So, on the third day of my rotation with the hospitalist group, my preceptor told me that I needed to learn how to tell sick from sick-sick. This is a variation on the idea of sick vs. not-sick that we discussed earlier. Those of you who are in medicine know that it takes time to be able to tell the difference very quickly from sick or not-sick. It takes a lot of experience and a keen eye, as well as (in some cases) a medical "sixth sense" that we students admire and hold in awe. "You mean, you can tell from the way the patient smells just how sick he is...?" - or some variation of this amazing set of skills.
Thus you might understand my reaction when my preceptor said (on a Wednesday), "I want you to learn the difference between sick and sick-sick and we'll review it on Friday." I knew what she was looking for so all I could do was blubber a, "Sounds goo-ood???" She passed on some hints to focus my research: Rapid Response Teams (RRTs). And thus I got the picture a little more fully.
RRTs are a group of providers in the hospital setting who are dedicated to being at the patient's bedside within five minutes of activation no matter what time of day. RRTs are made up of physician(s) (sometimes specialists, sometimes just ER or Intensive Care doctors), PAs (sometimes), Nurses (the backbone), CNAs, Respiratory Therapists, etc. who all have trained together and come together at any time to manage a patient who is, essentially, rapidly getting worse and on the verge of dying in the hospital. It makes sense to have such a team. So when should we call them?
This is the question - when do we activate the RRT and get this medical juggernaut rolling along to save a life? How do we know when they need to be called? The short answer is this: how does the patient look? But this isn't a well enough guided answer. To a noob like myself, a patient might look "Bad, but not really bad," when in fact they are two steps shy of meeting their maker. Thus, many great minds have gotten together and created some criteria for the activation of RRTs. One sample is as follows:
Respiratory signs:
Resp rate less than 8 or greater than 28
SpO2 of 86-90% for greater than 5 minutes
Increasing amounts of supplemental oxygen to maintain SpO2
PEDS - child (18-30), infant (30-60)
* Any significant change in respiratory status*
CV signs:
Rate 40-160 or
Rate greater than 140 with Sx
PEDS - child/adolescent (60-140), infant (85-190)
*Any significant change in pulse with Sx*
BP signs:
Systolic 80-180
Diastolic > 100
PEDS - age x 2 systolic
Neuro signs:
ALOC
Acute mental status changes
Unexplained lethargy/agitation
Seizure
Stroke Sx
- loss/change of speach
- sudden loss of movement/weakness of face/arms/legs
- numbness and tingling
Chest Pain:
No response to NTG
Acute or new onset
Other changes:
Pain
Fluid Status
Skin color (pale, dusky, blue)
Uncontrolled bleeding
Behavioral Emergency
This is the most comprehensive list of activation criteria that I could find. It comes from the Institute for Clinical Systems Improvement protocol that you can go do by clicking here. The utility of this set of guidelines is that it helps us to have some hard and fast references for activation. As one nurse that I interviewed about this topic said, it gives you something to know early on... After you get these numbers down and understand what they might indicate, then you can put it all into the context of the patient and the clinical picture and it will help you know sick from sick-sick (this is paraphrased).
A medical intern's perspective on this topic can be found here. This intern's perspective is what led to my interview of the nurse that I referenced above. Thus, another note to all of us who are fledglings out on the wards: ask your nurses... They'll be the first to know if something is going wrong - if you find out what they know, you'll have a much better chance of doing the job well.
Thus you might understand my reaction when my preceptor said (on a Wednesday), "I want you to learn the difference between sick and sick-sick and we'll review it on Friday." I knew what she was looking for so all I could do was blubber a, "Sounds goo-ood???" She passed on some hints to focus my research: Rapid Response Teams (RRTs). And thus I got the picture a little more fully.
RRTs are a group of providers in the hospital setting who are dedicated to being at the patient's bedside within five minutes of activation no matter what time of day. RRTs are made up of physician(s) (sometimes specialists, sometimes just ER or Intensive Care doctors), PAs (sometimes), Nurses (the backbone), CNAs, Respiratory Therapists, etc. who all have trained together and come together at any time to manage a patient who is, essentially, rapidly getting worse and on the verge of dying in the hospital. It makes sense to have such a team. So when should we call them?
This is the question - when do we activate the RRT and get this medical juggernaut rolling along to save a life? How do we know when they need to be called? The short answer is this: how does the patient look? But this isn't a well enough guided answer. To a noob like myself, a patient might look "Bad, but not really bad," when in fact they are two steps shy of meeting their maker. Thus, many great minds have gotten together and created some criteria for the activation of RRTs. One sample is as follows:
Respiratory signs:
Resp rate less than 8 or greater than 28
SpO2 of 86-90% for greater than 5 minutes
Increasing amounts of supplemental oxygen to maintain SpO2
PEDS - child (18-30), infant (30-60)
* Any significant change in respiratory status*
CV signs:
Rate 40-160 or
Rate greater than 140 with Sx
PEDS - child/adolescent (60-140), infant (85-190)
*Any significant change in pulse with Sx*
BP signs:
Systolic 80-180
Diastolic > 100
PEDS - age x 2 systolic
Neuro signs:
ALOC
Acute mental status changes
Unexplained lethargy/agitation
Seizure
Stroke Sx
- loss/change of speach
- sudden loss of movement/weakness of face/arms/legs
- numbness and tingling
Chest Pain:
No response to NTG
Acute or new onset
Other changes:
Pain
Fluid Status
Skin color (pale, dusky, blue)
Uncontrolled bleeding
Behavioral Emergency
This is the most comprehensive list of activation criteria that I could find. It comes from the Institute for Clinical Systems Improvement protocol that you can go do by clicking here. The utility of this set of guidelines is that it helps us to have some hard and fast references for activation. As one nurse that I interviewed about this topic said, it gives you something to know early on... After you get these numbers down and understand what they might indicate, then you can put it all into the context of the patient and the clinical picture and it will help you know sick from sick-sick (this is paraphrased).
A medical intern's perspective on this topic can be found here. This intern's perspective is what led to my interview of the nurse that I referenced above. Thus, another note to all of us who are fledglings out on the wards: ask your nurses... They'll be the first to know if something is going wrong - if you find out what they know, you'll have a much better chance of doing the job well.
Saturday, April 16, 2011
Families and Medicine
One of the items on our checklist of things to practice during this rotation is consulting with family members. This has been particularly interesting as it is something that healthcare providers do very often, but not something we think an awful lot about. We, of course, learn "people skills" as part of our training (as much as "people skills" can be taught) but it is not something that we study in depth like we would cardiology or acid-base disorders. But I have to say that this rotation has been particularly rewarding because talking to the families has been both valuable and enjoyable now that I'm focusing on it a little.
I have found that the best rule of thumb about this topic is that we as providers simply need to listen. We are taught that we need to listen from day one. We need to listen to the patient because if we do, they will likely tell us the diagnosis. The same applies to listening to the patient's family. You will learn how to make them happy and take care of their concerns if you just listen. This takes a couple of different forms - of course, we need to listen with our ears to what they say. Answer their questions thoroughly, without guessing, and with complete honesty. Additionally, we can listen with our eyes - something like 90% of communication comes via non-verbal means. This applies to patient's families as well. Many times, patients will be reticent to express concern or discomfort with the situation verbally, so they will do it by fidgeting or having a constricted affect or something along these lines. Providers can pick up on this via observation of the family and we can head off future problems by addressing their comfort level (or lack of comfort) early even before they have had to say anything about it.
I have had the pleasure of dealing with many family members over the past three weeks. I have earned their trust, answered their questions, and put them at ease about their ill loved ones. I have listened to them and it has been great. So, my advice to other students, learn to listen.
I have found that the best rule of thumb about this topic is that we as providers simply need to listen. We are taught that we need to listen from day one. We need to listen to the patient because if we do, they will likely tell us the diagnosis. The same applies to listening to the patient's family. You will learn how to make them happy and take care of their concerns if you just listen. This takes a couple of different forms - of course, we need to listen with our ears to what they say. Answer their questions thoroughly, without guessing, and with complete honesty. Additionally, we can listen with our eyes - something like 90% of communication comes via non-verbal means. This applies to patient's families as well. Many times, patients will be reticent to express concern or discomfort with the situation verbally, so they will do it by fidgeting or having a constricted affect or something along these lines. Providers can pick up on this via observation of the family and we can head off future problems by addressing their comfort level (or lack of comfort) early even before they have had to say anything about it.
I have had the pleasure of dealing with many family members over the past three weeks. I have earned their trust, answered their questions, and put them at ease about their ill loved ones. I have listened to them and it has been great. So, my advice to other students, learn to listen.
Saturday, April 2, 2011
Hospitalists
This month I am doing a rotation with a group of hospitalists. A hospitalist is a medical provider who works, as you might guess, in a hospital. These providers are responsible for the day-to-day management of patients who have been hospitalized for conditions ranging from severe pneumonia to flares of inflammatory bowel disease. In smaller hospitals, the hospitalist also covers the intensive care unit (the really sick-sick patients). So, I am getting a dose of very intense medical training - and I love it.
So far, I have had a patient who nearly died from very manageable conditions that got out of control very quickly, a patient with pain disproportionate to physical findings, severe pneumonia possibly complicated by malignant disease, and one patient with blood counts that are completely abnormal and that I have found very difficult to interpret (these are just a few examples among many). I have been challenged every day and this rotation is absolutely fascinating. If I could, I would become a hospitalist PA (and I might someday, if we ever decide to move to a big city).
Of interest is the fact that hospitalists as a specialty have only been around for a relatively short time (somewhere around 15-20 years). In the good 'ol days, day-to-day management of hospitalized patients was the responsibility of the family practice provider (be that a doctor, PA, or NP). But as family practice providers have grown increasingly busy, managing the really sick patients in the hospital became unfeasible. Thus, hospitalists became the next link in the medical-provider-chain. It's a very intriguing specialty - where else can you manage someone with acute abdominal pain who is alert and talkative one moment and seconds later be preparing another patient for the operating room so they can have life saving surgery? This is like zero to a hundred miles per hour in the blink of an eye.
I wish I could share more details, but a lot has been said recently about public media and medical/PA students who have gotten in trouble for just that. I'm erring on the side of caution such that none of my patients can be identified. After all, I would like to graduate.
So far, I have had a patient who nearly died from very manageable conditions that got out of control very quickly, a patient with pain disproportionate to physical findings, severe pneumonia possibly complicated by malignant disease, and one patient with blood counts that are completely abnormal and that I have found very difficult to interpret (these are just a few examples among many). I have been challenged every day and this rotation is absolutely fascinating. If I could, I would become a hospitalist PA (and I might someday, if we ever decide to move to a big city).
Of interest is the fact that hospitalists as a specialty have only been around for a relatively short time (somewhere around 15-20 years). In the good 'ol days, day-to-day management of hospitalized patients was the responsibility of the family practice provider (be that a doctor, PA, or NP). But as family practice providers have grown increasingly busy, managing the really sick patients in the hospital became unfeasible. Thus, hospitalists became the next link in the medical-provider-chain. It's a very intriguing specialty - where else can you manage someone with acute abdominal pain who is alert and talkative one moment and seconds later be preparing another patient for the operating room so they can have life saving surgery? This is like zero to a hundred miles per hour in the blink of an eye.
I wish I could share more details, but a lot has been said recently about public media and medical/PA students who have gotten in trouble for just that. I'm erring on the side of caution such that none of my patients can be identified. After all, I would like to graduate.
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