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.

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. 

Break Time

It has been a while since my last post...  Sorry I haven't kept up well.  Life has been a whirlwind - I spent four weeks away from home at my psychiatric rotation and the following two away from home for an endocrinology selective rotation.  All-in-all a good six weeks, but I was glad to get home last week and finally sleep in my own bed for more than two nights in a row. 

I have been trying to use this past week as a chance to recharge the batteries and help my family out as much as possible.  I initially thought I'd have tons of time off and we could relax and just fellowship a whole bunch...  But I was wrong.  I have actually worked more this week on homework than the last month combined.  I have been trying to catch up on a number of projects for school, some home projects, EMT recertification, a side project for my EMS division chief, running ambulance calls, taking care of the children so my wife can see some of her friends, spending time with some of our mutual friends, meetings in Spokane with advisors and a PA working in orthopedics, helping a friend with a project at home, just trying to spend down time with the kids, making sure my wife still knows who I am....  Oh, and sleeping as much as possible.  It has been the busiest week on record in a very long time. 

All that said - things have gotten done that I've been putting off for a while and it appears as if I am almost completely caught up.  Yesterday we raised a glass to St. Patrick and, if I had the time, tonight I'd raise a glass to accomplishments. 

The little things...

Today I want to post about the little things that make the grind of PA school a little bit better.  This is meant to be something of a celebration as we are now 190 days out from graduation and being done with all challenges associated with school (and after those 190 days, I get to enjoy all the challenges that come with actual work, but that's for another post). 

First, and foremost, my wife has made it all endurable.  She has helped me in every way from taking care of the kids with often minimal input from me to packing me a lunch almost every day for the past 1.5 years.  She deserves high praise and all my love for her endurance and her efforts, and the fact that yesterday she had to take a "rain check" valentine from me for something really special next year when the finances are more stable.  

But today, the biggest "little thing" is that they gave me an office.  It isn't much to look at, but the benefits one receives from having a quiet place to eat lunch or do a chart review are marvelous for one's psyche. 

Digging deep...

This week I had a chance to go back to the school office and chat with one of our faculty members about how everything is going and share some stories about lessons learned over the past six months.  It was a good time, mostly filled with laughter at all of my shenanigans.

One episode that I haven't shared yet occurred during my orthopedic surgery rotation and drew a raucous laugh from my former instructor.  It was an early morning, before 0700 and we were preparing to perform a total knee replacement on an elderly woman.  Just the previous week I had been verbally cautioned against scrubbing in too soon because it made me useless in prepping/positioning the patient.  This morning, I was determined not to make that mistake, so I waited in the hall outside the OR with my attending and his Nurse Practitioner.  They were hurriedly doing their last minute tasks and I didn't have anything to do.  The NP told me to get scrubbed and I began to meander through the task not wanting to get done too soon (in the end, I was simply woefully unmindful of the situation).  As soon as the attending stood up and started getting ready I snapped to scrubbing my hands and getting ready, but it was already too late.  They finished scrubbing moments ahead of me and the attending stepped into the room one step ahead of me.  And here is where I made the mistake: I didn't realize that stepping into the OR behind the attending was tantamount to being 20 minutes late to surgery - ie it was a total disgrace to me and I should be ashamed of myself.  The attending took the opportunity to inform me of my failure in front of all of the OR staff.  I was behind him, so he couldn't see the look on my face or the sweat beading on my brow, but the rest of the OR staff could.  There were a few snickers and chuckles (well deserved), but in the end I got gloved and gowned and did my job at the side of the operating table.  I was adequately shamed and I never repeated that particular error.

As I talked with my former instructor, this story brought much delight.  But we talked about other things going on - about psychiatry, about the struggles that PA school has brought with family, money, and time.  After I left I kept feeling that gut feeling that anyone who has played competitive sports has felt.  That feeling that says, "Time to dig a little deeper... It's fourth quarter, we're holding on to the lead just barely, and the other team has just put in a fresh set of players."  It's that feeling of exhaustion, pride, diligence all mixed together but looking at a finish line that is a full lap in the distance...  It's time to dig deep so that I can finish strong.  I have fewer than 200 days left, just six months.  I am fully 4/5 of the way through PA school and though things have been tough, we are doing quite well.  My prayer is that God will finish what He has started well, and I have no doubt that He will be faithful to do so.  But I know, through this feeling, that without Him I would be struggling very much.

Confessions

As difficult as it is to admit this, there are times at the psych ward that scare me.  I am not one to be easily put-off.  In fact, I deal with most incidents that might make one frightened well (though, if you ask some people I scared easily when I was a teenager).  Whatever the case may be, some of the patients on the psych ward give me the creeps, the heebee-jeebees, and otherwise make the hairs on the back of my neck stand up. 

The reason: we have some patients who are not your run-of-the-mill mentally ill folk.  We have a couple of hard core patients who have gone above-and-beyond - they are psychotic criminals.  These are the guys who hear voices in their heads ("nice" or "happy" voices some say) that tell them to do things like kill their entire family.  Now, admittedly, none of them have killed anyone.  But they have caused serious, permanent disfigurement of others as well as themselves.  And these guys are the ones who make me look over my shoulder every time I unlock the ward door at night.  They are the ones who cause me to sit with facing all entrances into the room, and they are the ones who make me extremely uncomfortable when we are in the same room together and they are between me and the door. 

Perhaps these guys are the reason I don't like psychiatry much.  I can't really pin it down.  But the other confession of the day is that I am having some trouble enjoying this rotation like I have enjoyed other rotations.  I am working shorter hours, I am home before the sun sets, and I get a one hour lunch break.  This is by far the least medically intense rotation I have had, but it is also the most mentally taxing in some ways.  Never before have I been required to NOT wear a tie for fear that I will be strangled with it.  At any rate, I certainly enjoy the medical side of what we do for our patients - and we do quite a bit.  One aspect that I have identified is that psychiatry has few objective measurements by which we can measure progress.  Much of what we know is subjective reporting and there are few examinations we can do to obtain any objective idea of how the patient is doing.  I suppose I prefer the objective measurement of a patient coming to the clinic or ER ill, receiving treatment, and leaving well. 

And once again I come back to the truth that there is yet much I need to learn - not all medicine is objective.  There is a lot that comes down to judgment of the provider and I know this in an academic sense.  Nowhere is this more important, in my fledgling opinion, than with psychiatry.  I welcome the challenge and hope that by the end of my time here I can gain at least a little bit of insight into this judgment. 

The psych ward

Today kicked off the first day of my psychiatry rotation.  I get to spend the next four weeks learning to manage the myriad psychological issues that will afflict my future patients.  To say that I had a deer-in-the-headlights look all day would be an understatement.  It was both frightening to the core and a remarkable experience. 

Beginning the day, I took the road to the hospital with cheerful confidence.  It is a nice leisurely drive from where we're staying to the hospital.  For the most part, the area is quite beautiful - wide open fields, gently rolling hills with long shadows dashing across them early in the morning.  The nearer to the hospital you get, the more the trees close in and the last stretch of road is a mildly creepy meandering road through the woods.  As the trees thin the hospital jumps into view, looming three stories above you.  It looks exactly as a psychiatric hospital should - pale brown bricks, a flagpole standing tall at the front door, and long wings stretching to either side of the main entrance.  The whole picture is topped off by that which only nature can provide - a permeating chill cuts through me and the grass crunches as a fresh coat of frost gives way under my feet. 

The day went just fine - there were no issues with any of the patients at all.  In fact, I enjoyed getting to know a couple of them and putting their angst-ridden minds at ease a bit with a few soft words and a plan to help them.  But the entire ward was, just as the outside of the hospital, exactly what one would expect from an institution like this one.  The lights were down low (in fact only every other light fixture was on), each door requires opening with a key are re-locking after passing through.  The basement (which is used by the staff as the main mode of movement from one building to another) is a half-lit labrynth of hallways and corridors, offices and conference rooms.  I was lost instantly.  Simply leaving the hospital at the end of the day took me a full 15 minutes and I have a set of keys to the place. 

Overall, this will be a challenging rotation.  I did not thoroughly enjoy my first day which I usually do.  I mean to make the most of the time I will spend here, but I anticipate that it will be a bit difficult.  Only time will tell.

Daylight

A few months ago I had been under the impression that I was busy.  I realize now what busy really means but what gets me is that I am still probably wrong about what I consider busy.  At any rate...

The past week has been rather intense.  We have seen 80+ patients over three days and performed 14 operations.  Each day has been longer than 12 hours for the surgeon and myself.  Of course, this week is offset by the prior week in which we only had 60 patients and 9 surgeries.  I understand that not all weeks are like this one, but it's still to the point that I have to ask myself - how do they do it?  I am thankful that I don't have a residency waiting for me in which these hours would be pretty much normal.  I don't envy anyone that mental stress but I also am thankful that I will not subject my family to that.  Not seeing the daylight for four straight days (literally) definitely has an adverse effect on me but also for my family. 

An important part of all of this is that we all (my family and I) will have to understand that there will be weeks like this one - there will be weeks when I need to work a lot of extra hours because there is a lot of work to be done.  We can handle that.  But we also need to understand that when the weeks are a bit slower, we need to recharge the batteries a bit - we need to let things be a little slower and spend some extra time doing family centered things.  I guess I need to point out that I need to learn to take it a little slower on the slow weeks - and it's something that everyone coming after me should take into account. 

My advice: as students, take the slow weeks to tend to the family/friends. 

Now, if only I could take my own advice. 

Orthopedic surgery

This past week has been spent learning the ropes of a local orthopedic surgery practice.  To say that we have been busy is an understatement.  We have had over seventy patients in the office (on the three days that we saw patients in the office) and have performed twelve surgeries.  It has been a whirlwind and I have tried my hardest to keep up.  Whether or not I have done that well is up in the air.  Regardless, I have enjoyed the ride. 

We began on Monday in the clinic doing some pre-op and follow-up appointments.  We had a few new patients, so in all it was a well-rounded day.  On Tuesday it was all OR - seven cases in total.  And we began the day with a procedure I had never seen before - a total knee replacement.  It was an eye opening day and I was reminded of how much I enjoyed the OR during general surgery some months ago.  More clinic and surgery on Wednesday, then Thursday just clinic.  Friday was another day of surgery in which we performed a meniscus transplant.  What an experience!  The surgeon took a piece of donor meniscus (knee cartilage) and sewed it into a patient whose knee cartilage was pretty much plum worn out. 

The emotional ride has been a little less extreme, but I am still humbled by all that I am doing now as a student.  The job that we have as medical providers is, in a word, huge.  I am enjoying learning that job and I am truly awestruck by the extent of what we need to know and be able to do.  At this moment, I feel very tiny in the world of medicine - as if I am too small to be able to do my job.  Yet in eight short months (ok - seven and a half, but who's counting?) I will need to be a functional part of this system.  I know I will get there, but it still seems so far away. 

Funny pictures

As anyone else, I enjoy a humorous picture every now and again.  This picture isn't quite as funny as the story behind the employees reaction when I took it.  First, the picture:

Then the story:
We were out at some establishment (I don't want to name any names, of course) and I happened to be wearing a jacket that identified me as a local ambulance company member (a Christmas gift from the company).  An employee had noticed my coat and wished us all a quiet evening (which didn't happen by the way).  As we were going about our business, we noticed that there was conspicuously no fire extinguisher on the wall and, what with the big sign and an arrow pointing to where it should be, we got a good laugh and I decided to snap a picture for giggles.  Well, the employee took note that an ambulance company member was snapping a picture of a place where a fire extinguisher is supposed to be and got just a little worked up -

"Wait, wait...  We have a fire extinguisher right here!"  She dutifully pulled one out from behind the counter.  "It just fell down and we haven't had a chance to put it back up yet," the look on her face a mixture of "got caught with a hand in the cookie jar" and "please don't tell anyone... it was an accident, honest."

I reassured the kind employee that I was snapping the picture for my own personal amusement and that I really do not care about the fact that the fire extinguisher is not exactly where the sign on the wall says that it should be.  I tried to convey that I was confident that they had everyone's safety well taken care of and that there was really nothing to worry about.  But I don't think I succeeded.  

In the end I got more of a chuckle out of the employee's reaction than I did over the photo itself.  And I realize that this means I am a horrible person.