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. 

Why.

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. 

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. 

In Other News...

I admittedly tend to ramble about the theoretical and conceptual aspects of medicine; the psychological challenges that I and my colleagues have faced, and the mindset we carry. 

But today I want to talk about a different aspect - my life as an EMT.  This job is still the most fun, if mostly because of the big kid in me.  I still get a kick out of turning those flashing lights on and sounding the sirens as we make our mad-dash across town.  It's a great group of folks, and we see some of the craziest stuff, get some of the most creative stories. 

Taking care of people on their worst day (or nearly that), while humbling, is still fun.  Today we were taking care of someone who was hurt pretty badly.  One of my partners said something that was mildly poetical in that it rhymed in a subtle way.  We were in the middle of carrying our patient who was having some trouble concentrating, but as soon as my partner said this funny little rhyme and I called it to all of our attention, our crew and the patient got a little chuckle out of it.  It was a nice reminder to me that, even in the middle of something kinda' scary, there is room for a little levity. 

I guess I did wax a little philosophical there, still thinking about the mindset we operate in.  Can't get away from that I guess.  But having a little fun while taking care of the sick and injured, that's a good day. 

Zebras

Today I am sitting in my office in the clinic.  It's one of the good days when I have a chance to catch up on paperwork and charts.  I need a break, so I'm going to discuss zebras.

There are a few great sayings that help us make reasonable and accurate diagnoses.  The first is this:

"Uncommon presentations of common problems are much more frequent that common presentations of uncommon problems." 

The second is this:

"When you hear hoofbeats, think "horses," not "zebras." 

A zebra in North America is a rare beast, indeed.  At the same time, they sound like horses as they run across the savannah.  Both animals have hooves that are quite similar.  If you saw one from afar you might think they are quite similar looking; if you just caught the silhouette of the animal against the sun then you could easily mistake a horse for a zebra or vice versa.  Thus we use the metaphor of zebras vs. horses to keep our heads on straight. 

When a patient comes in complaining of nausea and vomiting you think that she probably has a stomach bug because this is the most common thing - the horse - that will cause her symptoms.  As a PA I gather her history, perform a physical exam and look for any signs that there could be something else going on.  I put the puzzle together.  There are a hundred things that can cause nausea and vomiting, so how do I know it's a simple case of food poisoning or a stomach virus she picked up from her grandchild?  I listen to the history, confirm it with a physical exam that rules out most of the other 99 things that it could be, and - shazam! - I make a diagnosis.  And yet occasionally....  Very occasionally....  I will catch a zebra.  Like the patient who comes in with nausea and vomiting as the primary complaint and, "Oh... by the way...  I have a little rash on my leg."  Some of my patients have the oddest little, "Oh, by the way..." symptoms.  Some that I've heard have included, "My tongue is all bumpy," "When I move my head like this, I sneeze," or, "When I press really hard on my face right here, it hurts."  To these three I reply, "everyone's tongue is bumpy," "then don't do that," and, "everyone's face hurts when they push hard enough to leave nail marks like you are doing right now."  But how do I weed out the random garbage from the real stuff?

The answer to that question really is the million dollar question.  And I'll be honest: I don't always have a good way to weed it out.  There are some conditions in which all of the signs point one direction yet there is that little piece of the history that bugs me.  It's like a frustrating, nagging buzzing in the back of my mind that leads me to look one step deeper - order one more test or one more image or examine one more part of the patient.  It's just that one thing that doesn't fit with a horse-type condition; it's that one symptoms or physical finding that, if truly present, makes this condition into a zebra.  Then again, there is the occasional nagging oddity that may prompt me to look deeper still - but then I find nothing.  I diagnose them with a common problem - a horse - and they go home only to have the zebra rear it's head and show itself in all its striped glory just hours after leaving my office.  Again, in honesty, this is the most frustrating thing I've ever experienced. 

So there you have my musings on zebras for the day.  They're rare, I try to look for them.  Often they are elusive, and if I'm lucky I'll catch onto the one thing that doesn't fit.  The one thing that shows the zebra for what it truly is.  Which brings me to another saying that I've often heard along the way:

"It's better to be lucky than good."

And I have to agree.

The First Aphorism

"Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgement difficult.  The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate."

The above is an interpretation of Hippocrates' first aphorism as interpreted and printed in "The Uncertain Art: Thoughts on a Life in Medicine," by Sherwin B. Nuland, MD.  I can't say yet that the book is any good - still only about three chapters into it.  But the aphorism itself is...  well, a single adjective doesn't really describe it well enough.  It is insightful, thorough, and something that each PA student, NP student, and medical student (osteopathic or allopathic) should be introduced to.  It is daunting to undertake the charges given; it is in some ways difficult to wrap ones brain around them all; it manages to convey in just a short piece of text the history of the medical profession, the responsibility that we all bear in our clinics, offices, and hospital wards, and even to provide ethical guidance to help us operate in gray areas. 

With all of these things in mind, I want to discuss it in a piece-by-piece fashion.  I can't tackle it all at once, obviously, so we'll begin with the first phrase - "Life is short, and the Art is long."

It is attributed that Hippocrates was discussing medicine when he penned this in roughly 400 B.C.  "The Art," thus refers to the art of medicine, I believe.  This appears to be widely accepted.  Life is short, and the Art is long - to me this says something on several levels. 

The first thing I take away from this is of course that my life will be too short to fully understand every facet of the art of medicine.  I will never know all that there is to know...  Nor will any of us.  Every month of every year (perhaps even every day) scientists and doctors (and PAs and NPs) discover new things about medicine that are, in some cases, revolutionary.  We used to believe that if someone was bleeding out on the ground then we should pump them full of fluid to keep their blood pressure up.  Just recently, with protracted wars in two theaters, we've discovered through methodical analysis of military medical records that normal saline or lactated ringers pumped into the body of a bleeding patient actually decreases their chance of survival.  Yet the principle has been our M.O. for greater than 5 decades.  I will never be able to sew in a coronary artery graft, nor will my doctor.  The cardiac surgeon who does these will never be as adept at managing an ankle sprain as I or the orthopedic surgeon downstairs are.  Not one of us will ever get it, 100%.  This has many ramifications - communication between us being the most obvious.  But willingness to cooperate and share responsibility for people - as I've talked about in the past - is another thing that comes to mind.  In order for our patients to get the best care possible with front line approaches, it requires a multiple-specialty team. 

On another level, this phrase shows me that when ailment strikes, the lives of our patients become quite short if we don't do the right things at the right moments.  Life is fragile in many ways when illness or injury comes into the picture.  The meaning of the second snippet could be that medicine can take too long to have its effect and save a life, or it can mean that in these instances when disease has struck there is much that needs to be understood in order to fix an ailing patient.  In an older patient with acute onset of delirium tremens in the setting of pancreatitis who sustains rib fractures and bleeding into the chest - where should I begin?  What are the physiologic mechanisms by which this patient has become sick?  How do I correct them?  Why does the calcium level in this patient's blood drop precipitously?  What is the mechanism by which the albumin is low?  What happens to this body when albumin is low and how do I correct it?  How do we manage the bed sores that might develop?  What is the physiology of respiration and how does it affect all of the other stuff I've already mentioned?  Would someone who wasn't well trained in the Art be ready to manage this patient when time matters and even an hour's delay could be the difference between life and death for this person?  Obviously the answer I'm getting at is, "No."  Life is short, and the Art is long. 

When taken at face value we can admit that life is indeed short, medicine indeed takes a lot of time to learn.  It takes even longer to become proficient with it.  This is perhaps the simplest meaning to be taken from the first phrase, but all of the other stuff that I mentioned is hidden more deeply underneath the surface.  And all of it, in the end, comes into play when we're taking care of our patients on a day-to-day basis. 

Hiatus

To those who read this on a regular basis - I'm sorry for being so lame as to give you nothing to read.  But here is the latest update.

I have taken a new job working as an urgent care PA.  You might ask what that is...  Then again, you might not.  But I'll tell you anyway.  Urgent care is exactly that - I see patients who walk into the clinic without an appointment and feel they have a minor emergency occurring.  Now, most of this is not actually emergent - a majority if what I see is sinus infections, ear infections in kids, strep throat, etc.  But about 30-40% of my practice is devoted to truly urgent issues: a weekend warrior (that's me!) breaks an ankle while playing flag football in the park; a child has really severe nausea and hasn't been able to keep anything down for over 24 hours and is becoming dehydrated; a dull knife slips...  You get the picture.  Ankle sprains, concussions (without loss of consciousness - that's another story), and the like are welcome in my urgent care.  And sometimes I see much worse stuff, too.  Pneumonia, blood clots in the lungs, heart failure - that kind of thing.  The job is remarkably challenging - I would not have believed myself capable of this pace, but it is remarkably rewarding.  I can take care of 30-40 patients per day and sometimes I'm able to restore them quickly, and naturally the instant gratification is very satisfying. 

So, that's where things are right now professionally.  I'm contemplating another post soon about the first aphorism...  Hopefully it won't be 2-3 months before I get around to it. 

PA Name Change

I think that it is about time I make my stance on this topic known publicly.  But first, a little bit of background for those who don't know what the title of this post is referring to.

In the 1960s the Physician Assistant profession became the brain child of one Eugene Stead, MD.  Dr. Stead believed that servicemen coming back from the war with extensive combat medical experience could be crosstrained for a year in general medicine and then begin working alongside physician colleagues practicing medicine.  His vision was that these men would extend the number of primary care providers available to stem what was at that time just a minor shortage.  He was right, we do a fantastic job of this.  His pilot program began at Duke University, and when these men graduated they were Physician Associates.  Shortly after his pilot graduates began their fledgling careers, these providers were renamed Physician Assistants and we have carried that name ever since.

Fast forward 50 years or so.  We remain in these roles taking care of our patients, practicing medicine and doing excellent work.  Physician Assistants form a crucial part of most medical practices in the nation.  We are almost 90,000 strong (depending on which resource you look at) and we are involved in pretty much every medical specialty.  In family practices and other primary care specialties we are essentially doing the same thing as our physician counterparts, though there are some limitations.  And for the past 20 years or so there has been a lot of discussion about returning to our roots as Physician Associates rather than Assistants.  The feeling among most of my PA colleagues is that the "assistant" moniker no longer represents what we truly do in the medical world anymore.  Initially there was an element of assistant-ship to what we did, but our role and jobs have evolved fairly extensively.  We are no longer assistants, but we are associates to our physician partners, helping to extend the number of patients that can be reached.  We still have some oversight, but it is no longer an apprenticeship or assistant role that we play; we are partners in medical care.

This year the debate is growing even more heated.  Past representatives of the American Academy of PAs have made their opinions know, petitions have circulated, and there may be a resolution in front of our decision making body at the national convention this year to begin the process of changing our name back to that of Physician Associate.  I have to admit that my stance on this is that the title of Physician Assistant is misleading to the people I take care of on a daily basis.  I often get, "What exactly is a Physician Assistant?  I thought you were the people who put the patient in rooms and took their vital signs and stuff."  When I tell people what I do or introduce myself to my patients as a PA, there are often questions and occasional sidelong glances of distrust.  I do feel that our title is misrepresentative.  As such, I support a name change.

The caution is that we as a professional association have to avoid alienating ourselves from the physicians who have always supported us.  Those of us pushing for a name change and the general public as well as our supervising/sponsoring physicians need to understand that we aren't pushing for independent practice or greater scopes of practice or any more leeway than we have now.  We are only trying to emphasize that PAs are much more than assistants - we are providers who diagnose and treat illness.  We have the training and skills to do much more than the assistant title connotes.  That is all.  We need that message relayed to the public and our patients via a name change.  We need it in order to foster greater trust and to cement ourselves in the medical community.  That is all.  The name change will not only benefit us, but will benefit our physician partners as well.  I see it as a win-win.

There are many who oppose the change, and their reasons aren't horrible.  But for the future of the profession and our own growth I am fairly certain we will need to move along in the name change process.  You will continue to hear about this as time goes along, so I hope this gives enough background.   It's a big debate, and I hope that we can partner with our physician and PA colleagues alike to resolve it in a way that benefits us as well as them but overall so that our patients will have a better idea of who we are.

Winning and Losing

Today started out less happy than most days. I got a call from a patient who had a serious problem - a problem I had been worried about developing. Part of the problem was brought on by the medicine I gave to my patient. It was a known risk, one that I felt was outweighed by the benefits that were experienced. My patient agreed with that, until we both realized that the opposite was true. The natural adverse effect of the medicine was worse than either of us expected. No harm is done, it is all completely reversible. The patient will, in the end, be fine. But the hardship and emotional stress was more than expected, and I was a contributor to that. Chalk one up in the "Loss" column.

But later in the same day, I checked my inbox and found a magical piece of paper. It was a radiology study result that another patient and I had been waiting for for over a month; the patient had in fact been waiting for about the past 6 months for someone to make the diagnosis and get this magic piece of paper in their hand. And today I got it. The results of this test explained some very concerning and dangerous symptoms, and more than that offered hope of a cure of these symptoms. It was very good news and a long time coming. Chalk one up in the "Win" column.

This is life now. Wins, losses... Big wins, and big losses. But more than that, each win is a patient, each loss is someone I am responsible for. The gambles, the risk/benefit analyses I go through each day end up affecting someone else in a large way. This is not news to me, but this is the first time that I have had such a stark contrast in the same day. The gamble for one patient did not pay off, while the roll of the dice on a diagnostic test for another patient was completely successful. I am thankful that, to this point, I haven't had to gamble with someone's life. But I know that it is coming. And days like these make me one step more prepared. But it is still humbling, still intimidating, and incredibly challenging. I am just hoping that I stack up a whole bunch more wins than losses.

Candy, Toys, or Recess?

I have been thinking about these three things frequently since my emergency medicine rotation over a year ago.  I may have commented on it at that time...  I don't recall and don't want to sort through a host of old posts to find it.  Suffice it to say that a wise preceptor of mine once told me that people who go to an ER or Urgent Care want one of three things: they either want candy (medicine), toys (protective equipment/braces/ace wraps, etc), or recess (time off from work/school).  I spent my day today doing urgent care (aka minor care) and it was evident that the desire to receive one of these things is present in nearly everybody.

I had a patient today who basically came in because of cramps.  As it turns out, the patient had not been drinking any water to speak of...  at all.  For days.  But this simple explanation was not sufficient.  This person was sick, according to relatives, and it had to be something worse than a water deficit.  For almost everyone else, there was medicine or bracing or just a day or two off from work that helped them leave happy as clams.  But for the one person who didn't get one of the three, there was little closure - little apparent relief given my assessment and treatment planning as well as the counseling on nutrition and hydration guidelines.

Several of my preceptors discussed with me the importance of "reassurance" as part of a treatment plan and counseling of my patients.  This works well for a few patients, but mostly only those who schedule routine office visits and yearly exams on a regular basis.  Reassurance for the "worried well" works fine in most cases...  For those who are convinced that they are emergently or urgently sick, a little "reassurance" is much more difficult to make sufficient.  At the same time, that should never keep us from trying.