The past few weeks have presented me and my family with the opportunity to work through the rigors of PA school while undergoing family tragedy. There have been a number of aspects to this struggle, as most of you have experienced with your own personal tragedies. We are by no means unique in this, but I am relating the story to share the experience with others so that they might better understand or at least commiserate with PA students and students of other medical professions. Again I apologize for being purposefully vague, but the details belong to us.
It began about three weeks ago when a routine doctor visit yielded bad news. News that we had dreaded, yet it came nonetheless. I was thankful for compassionate preceptors who allowed me some time to deal with the bad news, but the next day I was back at work trying to make good decisions and be precise through a muddied mind, distracted (gladly so) by grief. I was grateful that I had a supportive environment and a can-do family, otherwise I would have been unable to bear the weight of everything going on.
The second chapter (or the last half of the first) came today - another phone call striking me in my emotional gut, leaving me distracted and unable to think about anything but my family for quite a while. But today, right after the phone call, I entered a patient room and the nice lady sitting there immediately started crying. It seems our life tragedies had coincided on this day. The difficulty I had was that my mind wanted to be elsewhere, my emotions were flowing in the equivalent of a re-entry tachy-arrhythmia - feeding upon themselves and blunting my empathy. I was able to push it aside for our hour-long (though it was only intended to be a 1/2 hour) appointment and we even made some progress... for the patient. Following that patient, I saw a lady I have been treating for depression and we worked through her struggles. At the end of this day, my mind is numb, I lack much emotion and despite the weight of what is going on around me, I feel less than engaged, not as present as I should be.
Thus today I had a valuable experience - balancing the emotional needs of my patients with the emotional needs of my family have become truly competing demands and I have worked through the first in what I am sure will be a long series of such episodes. I can't say I have achieved success - it is too early to tell. But I have survived the day, my family is resting at apparent peace, and my patients ambled back through the waiting room with many a thank you, appearing content with meds in the pharmacy and consults/referrals ordered.
God is good, even in times of great trial. May we never forget it.
Monday, July 11, 2011
Saturday, June 25, 2011
Fixing children
I want to share a brief experience I had the other day that left me feeling essentially elated over the fact that I will soon be able to practice medicine.
The case was almost as straightforward a case as it gets - I won't include any details at all so it will be quite a vague recollection. At any rate, a kid comes into the clinic not feeling well. I took a thorough history, did a thorough exam, and everything was pretty unremarkable. I selected a medicine that would treat the symptoms well and allow the child to recover essentially without intervention aside from some short term diet changes. The kiddo had a very good response to the medicine, I monitored to make sure there were no side effects and that the medicine was indeed having the desired effect, and the child's persona changed on the spot. It went from looking and feeling sick to looking like a normal little one and almost bouncing down the hall on the way out the door. The turnaround was drastic, and gratifying.
Family medicine definitely has its perks, and fixing children is a BIG one.
The case was almost as straightforward a case as it gets - I won't include any details at all so it will be quite a vague recollection. At any rate, a kid comes into the clinic not feeling well. I took a thorough history, did a thorough exam, and everything was pretty unremarkable. I selected a medicine that would treat the symptoms well and allow the child to recover essentially without intervention aside from some short term diet changes. The kiddo had a very good response to the medicine, I monitored to make sure there were no side effects and that the medicine was indeed having the desired effect, and the child's persona changed on the spot. It went from looking and feeling sick to looking like a normal little one and almost bouncing down the hall on the way out the door. The turnaround was drastic, and gratifying.
Family medicine definitely has its perks, and fixing children is a BIG one.
Tuesday, June 21, 2011
Jading
This post is as much a request for feedback from experienced professionals as it is a warning to those who will be PA, NP, or medical students reading these words later on.
In several of my rotations I have noticed that some of the more seasoned providers have become rather presumptive about some of our patients. Granted, they know our patients better than I do and I am still the student so I have to learn to approach difficult patients with caution. But the providers I have worked with that I am talking about herein are providers who have made assumptions about our patients like, "He just wants pain meds," or, "She's just looking to get high." It appears from my perspective that these providers are becoming jaded with their experiences, as if they've been burned by drug seekers too many times to be able to remain objective and avoid jumping to conclusions. I say this because I, in my naivety, have approached them with a blank mind (quite literally sometimes) and have found some pretty profound pathology - a patient who I suspect of having an ACL tear, or a patient who has significant osteoarthritis, and several others.
To the experienced providers I ask this: is there a method by which you have avoided this pitfall so as to maintain functional ability with difficult patients? It is my short experience that if we can maintain a sensitive approach to even our most difficult patients, then we will be able to treat them more effectively. Am I wrong?
To those students who are coming after me, I offer you this from my experiences (stop me if you've heard this story): many months ago I was working in the ER when a patient bounced back from earlier that day. This was a young girl who had been complaining of back pain but now she was coming in with severe abdominal pain. In passing a nurse commented about her prior visit to the ER and the likelihood that she had, "Just not gotten what she wanted." I bought into that thinking about her right away and it was reinforced as I watched her roll by on the stretcher writhing in pain. As I went in to examine her I was unimpressed by her pain given that she reacted excessively to every test that I did - minor pressure on her belly elicited near screams. She had no other symptoms that I could find. I presented the case to my preceptor who taught me a valuable lesson that day - he said, "Yeah, it could be a bounce-back because she didn't get the meds she wanted... Or she could have something wrong in her belly, so let's look." He ordered an ultrasound and found a GIANT ovarian cyst, reaching nearly up to the patient's ribs. As soon as I heard that I hung my head in shame... I had made a bad assumption based on very little evidence, and I was dead wrong. I would have been infinitely better as a provider if I had not assumed as much as I did, and I hope that I never forget the shame I felt that day - it was a good teacher.
In several of my rotations I have noticed that some of the more seasoned providers have become rather presumptive about some of our patients. Granted, they know our patients better than I do and I am still the student so I have to learn to approach difficult patients with caution. But the providers I have worked with that I am talking about herein are providers who have made assumptions about our patients like, "He just wants pain meds," or, "She's just looking to get high." It appears from my perspective that these providers are becoming jaded with their experiences, as if they've been burned by drug seekers too many times to be able to remain objective and avoid jumping to conclusions. I say this because I, in my naivety, have approached them with a blank mind (quite literally sometimes) and have found some pretty profound pathology - a patient who I suspect of having an ACL tear, or a patient who has significant osteoarthritis, and several others.
To the experienced providers I ask this: is there a method by which you have avoided this pitfall so as to maintain functional ability with difficult patients? It is my short experience that if we can maintain a sensitive approach to even our most difficult patients, then we will be able to treat them more effectively. Am I wrong?
To those students who are coming after me, I offer you this from my experiences (stop me if you've heard this story): many months ago I was working in the ER when a patient bounced back from earlier that day. This was a young girl who had been complaining of back pain but now she was coming in with severe abdominal pain. In passing a nurse commented about her prior visit to the ER and the likelihood that she had, "Just not gotten what she wanted." I bought into that thinking about her right away and it was reinforced as I watched her roll by on the stretcher writhing in pain. As I went in to examine her I was unimpressed by her pain given that she reacted excessively to every test that I did - minor pressure on her belly elicited near screams. She had no other symptoms that I could find. I presented the case to my preceptor who taught me a valuable lesson that day - he said, "Yeah, it could be a bounce-back because she didn't get the meds she wanted... Or she could have something wrong in her belly, so let's look." He ordered an ultrasound and found a GIANT ovarian cyst, reaching nearly up to the patient's ribs. As soon as I heard that I hung my head in shame... I had made a bad assumption based on very little evidence, and I was dead wrong. I would have been infinitely better as a provider if I had not assumed as much as I did, and I hope that I never forget the shame I felt that day - it was a good teacher.
Sunday, June 12, 2011
Family Practice
Seven weeks ago I started my last clinical rotation - Family Practice. The first thing that struck me was that I was very excited to be starting my last clinical rotation. It's a little bittersweet, but mostly sweet so I like that very much.
Family practice is a different animal than any other specialty that I've worked in (for the most part). Here I have to be a Jack-of-all-trades, master of none. I have to understand and treat the major Ears/Nose/Throat (ENT) issues for infants, children, adults but I have to know when to refer to the ENT specialists when the patient keeps getting sick or when my treatments are not successful. The same goes for cardiology, pulmonology, gastroenterology, urology, neurology, dermatology, orthopedics, rheumatology, hematology/oncology, endocrinology - you name the specialty and we dabble in it. It is a MASSIVE amount of information to understand and have a handle on. Putting it into words is even more intimidating than just thinking about it - seeing that list is nearly frightening. Yet somehow, day in and day out, I go to work and know what I'm talking about for the most part.
In addition to all that stuff, we also run a sort of minor care/emergency clinic through our family practice. This is for those things that just can't wait but aren't necessarily bad enough to go to the ER. Interestingly (very), since we are out in the boonies, we actually get a LOT of patients through our "quick care" that actually would be good candidates for the ER - women with severe lower abdominal pain and positive pregnancy tests, old men with crushing substernal chest pain, children who come in slightly confused with a fruity odor to their breath and blood sugars in the upper 500s. We get it all here and we have to know how to quickly and efficiently get the answers that we need to make nearly critical decisions. This part I love, very truly, but this is quite possibly the scariest thing I have done yet. The other day I had an older woman with diabetes tell me that it felt as if someone was sitting on her chest, but she just thought it was a bad reaction to her medicine and she wasn't even going to come in that day, but the clinic was conveniently located so she did. The problem: we are 40 minutes away from definitive care if the patient goes by ambulance - it would take the ambulance 20 minutes to get to us and 20 minutes to get the patient to the hospital. If something goes very wrong, we are essentially on our own.
So the last seven weeks have been yet another lesson in being appropriately uncomfortable which I am all the time. I have to work remarkably hard to know my limitations and stop myself from going over them. I am at the point now where I can see a patient in 20 minutes and have a good plan that will get to the root of the diagnosis, but I still consciously think, "Ok, what else could this be that might kill the patient if I don't look at it?" I do a few more tests than the experienced providers, but so far it's all been reasonable so I feel confident that even though I don't know and I'm uncomfortable I will still get the diagnosis that I need. And so far, I have. The pinnacle: I made a diagnosis of malignant melanoma on a patient who had a previously benign lesion re-occur. So, you never can tell what will come of a test or what might walk through your door - and that makes me uncomfortable, but I am slowly becoming ok with that.
Family practice is a different animal than any other specialty that I've worked in (for the most part). Here I have to be a Jack-of-all-trades, master of none. I have to understand and treat the major Ears/Nose/Throat (ENT) issues for infants, children, adults but I have to know when to refer to the ENT specialists when the patient keeps getting sick or when my treatments are not successful. The same goes for cardiology, pulmonology, gastroenterology, urology, neurology, dermatology, orthopedics, rheumatology, hematology/oncology, endocrinology - you name the specialty and we dabble in it. It is a MASSIVE amount of information to understand and have a handle on. Putting it into words is even more intimidating than just thinking about it - seeing that list is nearly frightening. Yet somehow, day in and day out, I go to work and know what I'm talking about for the most part.
In addition to all that stuff, we also run a sort of minor care/emergency clinic through our family practice. This is for those things that just can't wait but aren't necessarily bad enough to go to the ER. Interestingly (very), since we are out in the boonies, we actually get a LOT of patients through our "quick care" that actually would be good candidates for the ER - women with severe lower abdominal pain and positive pregnancy tests, old men with crushing substernal chest pain, children who come in slightly confused with a fruity odor to their breath and blood sugars in the upper 500s. We get it all here and we have to know how to quickly and efficiently get the answers that we need to make nearly critical decisions. This part I love, very truly, but this is quite possibly the scariest thing I have done yet. The other day I had an older woman with diabetes tell me that it felt as if someone was sitting on her chest, but she just thought it was a bad reaction to her medicine and she wasn't even going to come in that day, but the clinic was conveniently located so she did. The problem: we are 40 minutes away from definitive care if the patient goes by ambulance - it would take the ambulance 20 minutes to get to us and 20 minutes to get the patient to the hospital. If something goes very wrong, we are essentially on our own.
So the last seven weeks have been yet another lesson in being appropriately uncomfortable which I am all the time. I have to work remarkably hard to know my limitations and stop myself from going over them. I am at the point now where I can see a patient in 20 minutes and have a good plan that will get to the root of the diagnosis, but I still consciously think, "Ok, what else could this be that might kill the patient if I don't look at it?" I do a few more tests than the experienced providers, but so far it's all been reasonable so I feel confident that even though I don't know and I'm uncomfortable I will still get the diagnosis that I need. And so far, I have. The pinnacle: I made a diagnosis of malignant melanoma on a patient who had a previously benign lesion re-occur. So, you never can tell what will come of a test or what might walk through your door - and that makes me uncomfortable, but I am slowly becoming ok with that.
Monday, May 16, 2011
Come a looong way...
About a month ago I finished what I thought was the greatest rotation I could possibly have had. It was my hospital rotation in which I worked with four of the best preceptors a guy could ever ask for. I worked in a medical/surgical unit with an ICU on the side. The service was responsible for 6-10 patients on any given day, though we averaged closer to 6 - so it was a small service. But the size of the service was PERFECT. I had plenty of time to interact with my preceptors while not keeping them from their work and I got to help in the care of some very sick people. It was incredible.
In the first week, my lead preceptor discussed her expectations with me. I was a bit unnerved when she said that she expected me to be able to operate at the level of a 4th year medical student or medical intern (the intern year is the year after graduation from medical school - so she expected I would perform on par with a new graduate MD). Another of my preceptors said the same thing, so it was confirmed that I would need to step up to the plate on this one.
The thought that I would be able to operate at the level of a 4th year med student or intern was, in my opinion, setting the bar a bit high. I didn't exactly understand what that entailed, nor did I expect that I would completely meet that standard. As it turned out, though, I enjoyed the rotation and was able to step up in a way that worked out well. I actually wanted to get to the hospital early to pre-round on the patients so that when we did actual hospital rounds I was ready to go. I rounded by myself, got the labs/imaging compiled from the night before and presented my patients on morning rounds to my preceptor. I got "pimped" plenty and learned volumes about that management of really sick patients. I could have spent the remainder of my clinical year at that site and been plenty happy.
As it turned out, it was recommended to me by two of my preceptors that I go to medical school - one noted that I think more like a doctor than PAs he's worked with in the past. In all, it was a really gratifying experience. A very high bar was set and I was able to step up and get the job done, even though I didn't think I'd make it at first. But I'm curious about something... Do PAs and NPs think in a different way than doctor's do? My take on this is that NPs might think a little bit differently given their basis in the nursing model, but in the end they gather information the same way toward the same end - they have to make the diagnosis and treat the same as anyone. PAs are trained in the medical model so I would definitely expect that all PAs would think the same way as doctors. In the end, "mid-level" providers need to think the same way MDs/DOs do - we all have to come up with the same conclusion which means gathering the same type of information and applying the same type of decision making tree to the clinical problem so that the patients don't suffer. Thus I was really surprised at my preceptor's comment that I think more like a doctor than a PA - I thought we were all supposed to be on the same page. So, to everyone who comes along after me please take this to heart: be diligent about your information gathering and apply sound clinical decision making in order to 1. better represent our profession and 2. ensure that your patients are getting solid medical care.
In the end, the biggest thing that this rotation showed me is just how far I've come. A year ago, I was busting my tail to get through my last set of finals, struggling to maintain motivation in order to better regurgitate simple information onto a page. After just a year I have come a long way. Thinking back, if I had thought a year ago that I would be expected to be doing the job of a 4th year medical student I would have laughed at the idea. But I made it... Now on to family practice.
In the first week, my lead preceptor discussed her expectations with me. I was a bit unnerved when she said that she expected me to be able to operate at the level of a 4th year medical student or medical intern (the intern year is the year after graduation from medical school - so she expected I would perform on par with a new graduate MD). Another of my preceptors said the same thing, so it was confirmed that I would need to step up to the plate on this one.
The thought that I would be able to operate at the level of a 4th year med student or intern was, in my opinion, setting the bar a bit high. I didn't exactly understand what that entailed, nor did I expect that I would completely meet that standard. As it turned out, though, I enjoyed the rotation and was able to step up in a way that worked out well. I actually wanted to get to the hospital early to pre-round on the patients so that when we did actual hospital rounds I was ready to go. I rounded by myself, got the labs/imaging compiled from the night before and presented my patients on morning rounds to my preceptor. I got "pimped" plenty and learned volumes about that management of really sick patients. I could have spent the remainder of my clinical year at that site and been plenty happy.
As it turned out, it was recommended to me by two of my preceptors that I go to medical school - one noted that I think more like a doctor than PAs he's worked with in the past. In all, it was a really gratifying experience. A very high bar was set and I was able to step up and get the job done, even though I didn't think I'd make it at first. But I'm curious about something... Do PAs and NPs think in a different way than doctor's do? My take on this is that NPs might think a little bit differently given their basis in the nursing model, but in the end they gather information the same way toward the same end - they have to make the diagnosis and treat the same as anyone. PAs are trained in the medical model so I would definitely expect that all PAs would think the same way as doctors. In the end, "mid-level" providers need to think the same way MDs/DOs do - we all have to come up with the same conclusion which means gathering the same type of information and applying the same type of decision making tree to the clinical problem so that the patients don't suffer. Thus I was really surprised at my preceptor's comment that I think more like a doctor than a PA - I thought we were all supposed to be on the same page. So, to everyone who comes along after me please take this to heart: be diligent about your information gathering and apply sound clinical decision making in order to 1. better represent our profession and 2. ensure that your patients are getting solid medical care.
In the end, the biggest thing that this rotation showed me is just how far I've come. A year ago, I was busting my tail to get through my last set of finals, struggling to maintain motivation in order to better regurgitate simple information onto a page. After just a year I have come a long way. Thinking back, if I had thought a year ago that I would be expected to be doing the job of a 4th year medical student I would have laughed at the idea. But I made it... Now on to family practice.
Saturday, April 23, 2011
Changes... They're a-comin'
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.
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.
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.
Friday, March 18, 2011
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.
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.
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