Tuesday, June 25, 2013

Little black book

Early on in my career, while I was but a neophyte PA student in a pressed white coat, eyes as big as saucers and hands that shook while doing procedures (probably a voice that shook, too), someone gave me a great piece of advise.  That was that I needed a little black book.  Not one for phone numbers...  No, no - I am many years beyond that stage (and a wink goes out to my beautiful wife).  Rather, our little black books should contain the tidbits of information that will need to be remembered precisely but that will flee our minds over time. 

What is the differential diagnosis for a reactive thrombocytosis (white blood cells are elevated in the absence of an infection)?  I can't remember these off the top of my head, but I have the 18 most common causes listed in my little black book.  If a person's hemoglobin A1C is 8.5, what has their average blood sugar been over the preceeding 3 months (yes, Dr. Evans, I know that the average life span of a red blood cell is 120 days and thus the A1C can actually extrapolate back 4 months in time...  I have not forgotten).  That, too, is written in my little black book.  What Arlet & Ficat stage is a femoral head that shows subchondral collapse and flattening of the femoral head?  Well, stage III of course - thanks to my little black book. 

On and on it goes.   I have written down common antibiotics to be used for obscure conditions.  I have written down how to firmly diagnose someone with having Fibromyalgia (you have to identify 11 positive areas of point tenderness that have pre-defined locations).  I can calculate corrected serum calcium levels for a low albumin.  I know the mangement goals for a woman who has gestational diabetes mellitus.  All because I wrote them down in my little black book. 

Because I am still a neophyte, my eyes will still occasionally grow to the size of saucers (though much less commonly now), and because I forget things.  I can't keep it all straight.  And thus the little black book is invaluable.  Truth be told, it was something I should have started while in PA school so that I could remember that the 3 most common causes of otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarhalis.  Oh...  I guess I did remember something from school. 

My advise to all those in practice and learning to practice: get a little black book.  The earlier, the better. 

Monday, June 17, 2013


A lot of discussion and thought has gone into the reasons why we in medicine do what we do.  A lot.  Doctors, nurses, PAs, EMTs, paramedics, respiratory therapists, and especially CNAs have thought about it.  I thought about it a lot as a CNA - why am I here, doing what I'm doing, as horrible as it is to endure?

I recently read a book entitled, "My Ambulance Education," by Dr. Joseph Clark, PhD.  It's the story about how he started working as an EMT at the age of 18 to pay his way through college.  He started taking care of people because it was a skillset he possessed that allowed him to do what others cannot.  He paid his way through undergraduate school, got a master's and eventually a PhD in physiology in order to help people on a grander scale.  He now does research into the causes and prevention of stroke.  He states in his book that he began to feel that helping one person at a time on the ambulance was not enough - that he was capable of more.  And now he strives to help thousands - probably millions - of people annually by figuring out a way to prevent strokes.  I like his approach.  Hard work pays off.

I have been asked why I do what I do.  Not so much on the PA side of my career, but on the EMT side of things.  I'm a volunteer as are we all in our department.  So the question - why do you do what you do and furthermore, why do you volunteer for it?  I've been mulling this one over a lot lately.  And the answers I keep coming up with are the same.  People need help and I want to help them for it is rewarding.  There is need out there and I want to take care of it.  I want to fix things for people.  This is the best I can do to answer the question. 

There may be another aspect to the answer; something that keeps recurring in my mind is that someone needs to answer the calls for help.  In a fallen world there will always be someone sick or injured and that person may well die without a neighbor stepping up and helping.  Someone needs to be there for those who can't help themselves.  And I guess that someone is me...  sometimes. 

If I come up with anything more profound, I'll be sure to let you know. 

Thursday, April 4, 2013

A strange thing happened on the way to.... Oregon.

Greetings friends and neighbors.

I have been away from the world of the internet for some time as I have not had a desire to post anything.  My father passed away and oddly enough I found that the fact that he read this blog was a big motivator for writing down the goings-on in the world of PA-dom.  To the rest who read this I don't want you to feel berated or belittled for I am motivated as well by the fact that you still read this...  oddly enough I had 20 pageviews just yesterday (?!?).  But when dad died I struggled with a lot of things, and still do to a moderate extent.  How do the French say it - "That's how it goes"?  Ok, I know that's not what the French say.  But it is true.  Life goes that way.  And praise God for the unpredictability of life. 

As I sit and write this, I have before me the (second) most recent "Neonatal Resuscitation Guidelines" published in "Circulation: Journal of the American Heart Association," 2010; 122:S909-S919.  I am reviewing it because I have taken on a new role, of which I am quite proud, in my clinic.  I am one of the first assists in C-sections.  Yes, that is a Caesarian section in which the abdomen of a gravid woman is opened surgically with the goal of delivering a healthy and happy baby.  This method of delivery is reserved for life threatening situations, generally speaking, or in cases when the mother has already had a C-section and vaginal birth after C-section (VBAC) is too risky (which, in my opinion, is very often - but that is a topic for another day).  Thankfully, in our practice, our C-sections are universally in cases when mom has had a C-section already, so there is little life-threat involved.  I prefer things to be that way.  As the first assistant, however, baby is my job.  After I cut the umbilical cord, it is my job to ensure that baby breathes on her own, pinks up normally, has good limb movement, cries, and overall just to ensure that baby makes a good transition for intrauterine to extrauterine life.  But there are things that can go wrong...  And sometimes babies don't do so well.  Life goes that way. 

I miss my dad often.  And I wish that I could tell him about what I do now.  Oh, sure, I do a lot of other fun stuff too.  But this, this barbaric but finely tuned method of bringing babies into the world, is by far the coolest.  I'm sorry I haven't shared it with you all until now.  But my hope is that as the loss wanes and I get over myself I will again share my passion for being a PA with others who read these words.  I have to trust God that life goes that way. 

Thanks for reading.