OK, so it has been a while......again.

So, I am done with pediatric internal medicine and have moved on to my elective.....Cardiothoracic surgery.

There are a few reasons that I asked for this rotation.

1) I know that I want to go into surgery and I hear that CT surgeons really utilize PA's more than any other surgeon. I wanted to see if CT surg was for me.

2) I heard that there was a possibility that this group might be looking to add another PA.

3) I heard that on this rotation, if I bust my ass, I will get to do a lot.

4) The more surgery experience I get the better.

5) Managing ICU patients scares the shit out of me, so I better get some experience while I am still a student and can fall back on that.

I had several people try to talk me out of this rotation. My preceptor has quite a reputation for being "difficult" and let me know on my first day that he has made several of our students cry. I knew this going in. I was encouraged by a student in the class before me to go on this rotation and was encouraged that with my personality I could handle it/them. I was also told that with hard work they would recognize that I want to learn and take me under their wings so to speak.

In the beginning of this rotation, I was bored. I was told in the first week, "you will get to scrub in next week". That surprised me as I have done sugery on 3 other rotations.....but I think that they are used to having students that this is their first surgery rotation, so I get it. Well, they actually let me scrub in on Wednesday of that first week......and anytime I want ever since.

In the beginning of this rotation I was thinking that I did not like CT surgery. Anything is boring if you only get to watch for 5 hours. SO, once I started to get to do things, I really started to like it! I got to put in my first chest tube solo today. I have been assisting the radial artery harvesting, and was told at the last one that I will be doing it next time.......

Well the other day that came true and I got to do a good portion of it myself!

I have been writing this over a series of a few days and a few developments have taken place. Seems like I am in high demand!! I am getting job offers left and right and people are trying to snag me. The question is......Seattle or Portland? Life or no life? No holidays or holidays? No call or call? The holidays and call would suck, but with them comes not only a ton of great experience to back me but a gigantic paycheck. The only question now is.....When do I start, and where?

It will definitely be nice to have the comfort of knowing that I will have a job waiting for me when I get out, but as of now, negotiations are stressful!!

Flying solo.....

Sometimes it is really nice when they let you take the reigns and fly solo. What a fun day! More to come, but 4am comes early....

After I was done, although the light hides my beautiful work!!

Tidying things up after a radial artery harvest for coronary artery bypass.

It's been a while.....

Hi everyone! So, I know that it has been a while since I have written anything, but family practice is just not that exciting. There are crazies and drug seekers, but I think that here, without EMTALA, we can kick them out and fire them as patients if we want. Simple as that.

The beauty, though of family practice is that I have time to have a life. Frankly, I don't know what to do with myself! It helps that former me (the other Lisa B. from Seattle that was my roomie in PA school) is here now, and that I will have her to hang out with. It is great but strange to be back in Seattle. Two of my best friends have moved away, and everyone else is having kids etc.

One thing that has been great is that I have a chance to get to the gym again. I started going a few weeks ago, but was still eating kind of crappy, and really not pushing myself to the limits that I knew that I could go so I made a decision. CrossFit. Don't know what it is? http://www.crossfit.com/

If, I am going to do this, I figure that I have to not get in my own way with my eating habits, so I am back to my old regimented ways.....but now, I'm going paleo. Basically it is eating anything that a caveman had acces to, like meat, berries, veggies, nuts. Basically all of your carb sources come from fruit and veggies. No sugar (or artificial sweeteners), no grains, no bread (sigh), no alcohol (although red wine and tequila are considered paleo alcohol), no caffeine (I will allow myself one coffe a day). I am going to do a modified paleo in that I am going to allow myself cream in my coffee, and cheese on certain things. Today is day one. I started crossfit almost a week ago, have gone 3 times, gotten my ass handed to me and loved every minute of it!!! Since starting the zone and going mostly paleo, I have lost 2 lbs in a week.

I don't expect to drop a ton of weight, but I do expect my body composition to change greatly. I already feel the difference in my mood and sleep. The only problem is that the first two days I woke up with a raging headache. Not so bad this morning though. I will keep you all updated on my progress on this. I look forward to getting my strength and my hot bod back!

11'ers, you will see a new, fitter me in 5 weeks!

I promise to post more interesting office antics soon. I will also post progress of my transformation! Todays difficulty.....resisting the free pizza and doughnuts. The doughnuts smell so good!

How about a nice warm glass of go f&@% yourself!

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Death number 2...

Last night was a little insane......but I like insane, so it was good for me.

The usual traumas coming in.....little old ladies falling down and hitting thier heads. One we think had a sneaker heart attack.

People getting shot with drug deals gone bad, but they were just "minding their own business" at 3 in the morning in a shady part of town.

Guy and his wife go to a strip club, someone says something to his wife, he punches the guy, turns out it is a bouncer, he then gets jumped by a bunch of bouncers.....and looks like it.

Then there is the "Level 1 trauma, direct to OR" page. That means it is a good one (actually a bad one). Ambulance rolls in, guy in on the gurney, pumping on this girl's chest. Stab wound to the right chest. I look at her and think, "That is what a dead person looks like." She is white, and her eyes are open. BUT, we still try to save her. It is insanity in there. It was one of those situations where they pour betadine on the chest and cut. Sawed her open to get to the heart. There is blood everywhere. She is still pulseless and we can't get any sort of presure into her. He's got her heart out of her chest and is manually compressing it. Epi straight to the heart. Then calcium, then bicarb, then Epi again, then we shock her heart. We have been at it for 10 minutes now (CPR was already done for 10 in the ambulance), but we decide to try for 5 more minutes, but literally she has lost all of her blood volume. Looking at where the blood was coming from, whatever stabbed her went into the right atruim of her heart. She didn't stand a chance really. It was crazy. Her "friend" that stabbed her went in at just the right angle that it went in her right chest, down at an angle between 2 ribs, and into her heart. I think it was tamponade that killed her before even bleeding out. Sad, the girl looked like she was in her mid 20's. This death was definitely real. She looked dead. It was strange to thing that she was dead......and tha someone that she knew did this to her. I'm not sure that that other person realizes the gravity of what she did. People amaze me.

Well off to more trauma tonight!

Warning....graphic images in this post.

Well the Civil war was a little more civil that I anticipated, but it was still a super busy night for us on the trauma team. A rundown of the night.

Guy in our unit in respiratory distress - drowning in his own secretions basically. Two hours trying to manage him. Eventually admitted him to the ICU.

Lady in our unit desatting to the 80's. She perks up with nebs, but is supposed to go to a nursing facility today. I have a sad feeling that she will be back to us with pneumonia and imminent death soon. She has some gnarly rib fractures and is in her 70's or 80's. That has over a 50% mortality rate. No joke.

Trauma - Fall 71yo, head bleed. Non-English speaking. REALLY hard to get a hx. Finally got an interpreter.

Trauma - Fall 71yo, head bleed. (yes again). She doesn't look 71. She is SUPER fidgety and twitchy. Hers was an alcohol related fall. She hit her head and knocked herself out. Here is where I was a little proud of my sleuthing skills. She says that she has been drinking for years, but that she only drinks 2-3 glasses of wine a night. So I ask, "Do you empty the bottle with those three glasses" to which she says, "Well there's a little left". SWEET, score for me! THEN, I later find out that her "bottle" is one of the liter and a half double wine bottles. Damn it! Now I have another question to add to the bank though! She required a buttload of sedation to stop moving in the CT scanner.

Trauma - fall 91yo, sweet as all get out. Possible cord involvement, but lower extremity weakness is resolving. Impressive cervical CT. Crazy looking at it that this lady has the use of all 4 limbs (old injury we are suspecting)

Trauma - 31yo - got drunk and crashed her car. Chunks of her hands taken away. Glass all in her wounds on xray. Her hands look like Freddy Kruger. She lost most of the skin and was down to ligaments and tendons. It was insane looking.

Called to OR for emergency surgery. They asked for the PA student to scrub in. I was like, "you're sure they asked for me?"

A girl about my age that has been on ECMO, had her spleen spontaneously rupture. They need another pair of hands in there to help. So I scrub in and it is insane. You are anti coagulated on ECMO, so she is bleeding like nobody's business. They are throwing deep ties on her splenic artery and other bleeders. They seem to get that under control, but there are other things like the liver that is spontaneously bleeding. They give me the bovie and ask, "do you know how to use this?" I say yes, and they say, "stop the bleeding." They are trying to work on her femoral artery to get a new line for ECMO in there. Meanwhile the bleeding is not stopping. The vessel gets a stitch, but she is bleeding from everywhere else. They get the other line, but her vessels are so clamped down that they can't really perfuse her. We did everything that we could but there just wasn't anything more that could be done to help her. So she died. It is sad. Sudden for her family, although she has been in critical condition. It doesn't even seem real.

Trauma 0530: Guy that fell at 11pm. Got drunk, fell down, was locked out of his house. Finally got in, looked at his head, realized that he needed to come to the hospital. Arrives to us at 0530 as a trauma. He is still wasted (1$ duck farts for any score in the game I guess) He comes to us with this. Impressive. I have his permission to take and use these pictures

Full moon = crazy? I think there's proof.

I usually don't blame things on the full moon, but the past few nights have been bizarre. A couple of nights ago, I saw my first dead person (that was not in cadaver lab). We got called to a code, but she was DNR. She looked peaceful (and dead). Then we get a trauma. Self-inflicted GSW to the head. Strange, the guy put a note in his pocket that said "Do not resuscitate. I am an organ donor" wow, he was planning ahead. BUT, I didn't even think about this, you can't take that at it's face value, because you don't really know that it was his handwriting. Turns out, that this guy was a bad boy and hurt someone else before he took himself out. He is on life support still, but it is a fatal wound. Transplant team on stand by. At least in his selfishness he was thoughtful enough to possibly help someone else with his organs. That is the only piece of light that comes out of that story.

That same night we had 5 traumas. 4 of whom were drunk. One guy stumbled into traffic and got hit. Tib-fib fracture that was almost open. You could see the bone trying to pop through the skin. THAT turned my stomach a little bit. This guy was wasted, and at first he kept screaming that the Portland police did this too him. Later he was saying that he hopes that the person that hit him is a doctor and drives a BMW. He then proclaimed that he would settle out of court for $10k. It reminded me of the scene in the movie Friday where the crack head guy acts like he falls in the mini-mart. This guy was a piece of work. He was saying that it was the 2nd time in a week that he had been hit by a car and that he doesn't know what is wrong with people and their driving (apparently, he just ran out into the middle of a busy street). His blood alcohol was 373 when he got to us. That is almost 5 times the legal limit.

Then we get the drunk lady that cries all the time. Got beat up by "a couple of whores" Former IV drug user, Hep C, chirrosis, etc. Crying because a nurse at the other hospital said something "mean to her". She is still crying. No matter what we do on the floor, she still cries. This lady has no coping skills (and no teeth). I don't know why, but I seem to be the only one that can talk her down. So I make an attempt to help the nurses by coming in to talk to her and calm her down a couple of times a shift. She has a small spine fracture, but we need to scope her because her rectal was positive for blood and her CT was ok. I think that she has probably got a leaky varices.

THEN, there is the serial killer looking kid. THis kid is creepy. He looks right through you. He got shot in the face while robbing two people at knife point. He has a pseudo aneurysm in his face that can kill him. He could have gotten a fibrinogen shot to make it go away or a really extensive facial surgery. He picks the surgery because that means he won't go straight to jail. Then he starts refusing all of his meds. He has a trach and a MRSA infection in his lungs, but refuses to cover his trach, so he coughs MRSA mucous everywhere. Pulled his foley, last night pulled his trach out, and is trying to pull his new PEG tube, which can also get really dangerous. There is way more to it, but I am in a time crunch and cant write it all. The point is he pulled his trach than told us to get a doctor to come sew it up. We told him that these don't get sewn up. He claims that he doesn't "need" and of this....like the feeding tube. But he can't swallow, and aspirates when he tries to swallow. AN psych left a great note saying, "the patient feels that he is stable" I am glad that psych is letting patients determine their own stability. I say that anyone that is decanulating themselves is a danger to themselves. Anyway, it will be interesting to see what has transpired with him over the day. We were at the point where we were going to have to call security last night because he was wandering the halls (planning an escape route I'm sure), coughing MRSA everywhere, which we just can't have. And literally, you will see like 1/4 cup of yellow mucous coming out of his trach. It's no joke.

Anyway, gotta run!

eeewwwwww...

So I officially got puked on last night. Luckily my cat like reflexes allowed me to see what was coming and 1) roll the guy onto his side, and 2) jump out of the way enough that I only got splatter on my shoes and scrubs. It SMELLED! I am so glad that they provide scrubs there. I changed eventually after the trauma was over, but the smell takes a while to leave your nose.

Background on the patient. Young guy...he and his friend hit on a couple of girls at a bar. The girls' guy friends come to their aid and break this guy's face....literally. Open mandible fracture. The kid was wasted. Asked him if he smokes......he says, "cigarettes or weed?" I say, "both". He says, "I smoke a pack a day of cigarettes but I smoke a hell of a lot of weed". Classic. Got to appreciate his honesty. Then I ask him if he drinks. He says "yeah but not a lot." I say, "How much", he says 2 40's 3 times a week"..........and I bet this dumb kid "pours some out for his homies" too. Poor little dumb-ass. I know that kids do stupid things, but I have a feeling that this will not be the last time that we see this guy....or his "bling".....nothing says pimp like a gold pinky ring. This guy doesn't know if he wants to be Tony Soprano or 50 cent........but is leaning the way of 50 I think.

Last night was my first night on nights. I LOVE nights! I love that I don't have to get up so early. I love that it is kind of free-form. I love that I am the one responding to the traumas. I love it all!

Patients lie.....

They tell you this is school, but it really does happen in Trauma especially......a few humorous examples.

Guy I have been following for a while with an ileus and also starting to work on a pneumonia REALLY needs to get up and at least sit up in a chair. This will help his bowels start to move again and will help clear the goop from his lungs. I try to emphasize this every day. Yesterday it was "I was up in the chair 3 times last night"......I am skeptical. Later he tells me "I guess I hallucinated that I was up yesterday. The nurse told me that I never got out of bed." At least he copped to it. He is on some pretty heavy pain meds. Good news is that he was up today and even asked for a cane so that he can try to walk. Good for him.

Guy number 2: Comes in with a blood alcohol in the 300's somewhere. Stab wound to the chest. He is still drunk after surgery that revealed that it only hit the muscle. He goes on with this story, saying, "I'm sorry, a man just can't call another man a bitch. Before I could pound on this dude's face he stabbed me!" (like he was shocked. If he had gotten his hands on the guy we would have seen both of them on our service, no doubt........Later in the day when he is more sober...and a total baby by the way .....most "gangster guys" are when they get on the trauma service. They seem TRULY surprised that a gunshot wound or a stab wound hurts). Anyway, the story after he sobers up is that some dude tried to rob him and take his wallet and stabbed him. He obviously did not recall telling us about the altercation earlier. Classic.

Guy number 3: First of all he is this Asian kid that things he is super gangsta, complete with street slang. Super dramatic. Came in as a "walk in" trauma at 9am or so....at this point his blood alcohol was still 188. Apparently sometime during the night he had gone to another ER, but left. So he had to have been really drunk last night to still have this level. This guy's eyes are swollen shut. He is telling us that he thinks that he got attacked. His injuries are telling us another story. He then proceeds to ask us if the police can call to see if he is in that hospital and if they can get his medical information. He says that he doesn't want his PO to know that he was drinking (another peach). We tell him that only if he were involved in a crime or if there were some reason that they were looking for him could they find this information out. We start putting 2 and 2 together. We had a guy who's face literally got stomped on and this is not looking like that at all. In fact looking at what the physical exam is telling us, his eyes look goopy. We start talking about it and we are thinking that he has chemical burns from an airbag (bases are worse than acids because they break down collagen...aka they liquefy most stuff that skin and eyes are made of).....he likely is remembering that he crashed his car (drunk) and is hoping not to go back to jail. Meanwhile the base that is in his eyes is dissolving the collagen and can likely do serious damage. This idiot does not realize that his trying to save his own ass can blind him. Idiot.

Part of the message here is to trust your physical exam. It will give you the info that you need most of the time. He must know that if we find out that he crashed while he was drunk that we need to notify the cops. Sucks for him. I guarantee that he will bail in the middle of the night when he gets wind that we have an idea of what really happened. Again....idiot. And if that doesn't work you tell him that anyone involved in an altercation and found down needs a rectal exam to make sure that he is not bleeding internally. That gets you more truth telling than you can imagine. ;-) Heehee, I love my job.

There's good news and bad news.....

Bad news: Life support removed from our little girl the other day. Really sad. Brother is not doing so hot either. That family really has a lot to deal with. My thoughts and prayers go out to them and the challenges that await them.

Good news: Trauma kicks ass! I keep working late...until almost 8 last night....which makes for a long day when you get to work at 5:45. But ALWAYS, and I mean always, the trauma pager goes off at right about 6, and I am not one to hand off the trauma pager and go "later". I try to make sure that I am not stepping on Brooke's toes, as she is on nights. Technically it is her trauma, but I still want to see what is going on. So I tend to at least hang around and see what transpires in the trauma before I take off. If there is more than one coming in, I will take one of them, but otherwise, it is Brooke's show and I will just watch. I figure the more I see, the more I will learn and feel comfortable when it is me standing there with nobody telling me what to do.....although Brooke and I are both kind of doing that now, but still, every trauma is unique, and I think that I learn something from each one.

Yesterday got to scrub in on a HUGE diaphragm rupture repair. It took 4 hours and was super difficult for the surgeon, but it was nice to be first assist. I also got to help put in a chest tube, and got to close (as usual). It really is interesting how different surgeons have different methods of closing. I scrubbed in on another procedure earlier that day and I saw a closure that I had never seen before. It was interesting......and not at all what I expected....but this guy really knows his stuff so I am not going to rock that boat. I just consider it another technique learned. Plus, he loves to teach, and is a really great teacher. That is a great combo. I have no life right now, and as I type this I am thinking, "It's an hour past my bed time", but I am learning so much and having a great time, so it is all worth it. I also really like the team that I am working with. There is a recent Pacific grad.....a couple of other Pacific grads and all of the PA's are REALLY knowledgeable. PA students, look for John Van Horn on your schedule. He is who I want to be when I grow up. Emanuel trauma is an example of how skilled, knowledgeable and autonomous PA's can really be. It is the best example of PA's that I have seen, and one that I hope to Emulate. Well, "It's past my bed time". More to come.....

AGAIN......Wear your seatbelts AND BUCKLE IN YOUR KIDS.

First thing this morning. Life flight. 2 month old, ejected from vehicle, unrestrained. I think 3 others dead on the scene. Surprisingly this kid is ok. I don't even think that he broke anything!

Not so good for the others though. Little girl from last night made it through the night/day, but is brain dead. Mom is in the hospital but ok. Brother is stable, and the other one is on it's way to our facility so that the family can be together. The teenagers that caused the accident are all ok and all smiles.......I don't know if they grasp the fact that they just disseminated an entire family. Damn lack of pre-frontal cortex! Teens don't realize the consequences of their actions.....they can't......that part of their brain isn't fully developed yet. I say, at least show some remorse for those that died. My job is not to judge but sometimes it is really hard not to want to. Even with these kids.....their injuries would be vastly different if they were in car seats or in seat belts even. The girl would likely have survived. But the reality is that mom is going to have to live with that for the rest of her life. That is really sad. Again, like I said.......it is hard not to judge. It is easy to point fingers at the mom and the teen, but the reality is that mom needs all the compassion and support that she can get right now. Who am I to judge her or anyone else? Who REALLY thinks that an accident is going to happen to them? Not very many people. Hind sight is 20/20, but this will be a hard thing to look back upon for that family.

On a different note. Pulled chest tube #2 today. Took 5 patients on my own, and felt more competent on rounds. It is a little easier on the weekends though when there isn't a gigantic posse rounding. Got pimped pretty hard today, but in a good, "I want to see what you know, to see what else I can teach you" way. I did really well. I even got a few eyebrow raises as in "I really didn't expect you to know that or get that right" kind of way. That felt good. Mind you, I did not know all the answers, but it felt good to be on the more right than wrong side of the curve.

Kids, wear your seat belts.....

Some lessons from trauma....and I already know this from surgery but was feeling extra lax today. Never eat when you are hungry. ALWAYS anticipate that you are not going to eat for another 6 hours. Hunger should not be in your vocabulary, for it is your enemy. I had a "slow" morning and went upstairs to read my trauma book and had some soup. I was feeling tired and nappish, but thought, "Well it is about noon, I better eat." ....rather than napping...a sure-fire way to get a trauma page. Low-and-behold....I get in the elevator and I get a page.....Level one trauma, life flight, ETA 5 min. I think to myself, "that isn't enough time to get lunch." and figure that I will get some food after that. WELL, it is a 5yo with bilateral femur fractures (open) and some head lacs. Things are calming down then the kid's 6 year old sibling comes in with major injuries. 3 hours later (after the initial trauma page) and we are going to surgery. I REALLY want to go but am feeling the tinge of a low blood sugar. Luckily one of the PA's has a cliff bar that I shove in my mouth in like 20 seconds (which is really hard to do).

So we get this girl into the OR and other than a ruptured AAA I have never seen anything quite like it. There were 3 surgical teams mobilizing and doing their thing at the same time.

This poor little girl had an open femur fracture (might have films....which has not yet been fixed). But that was the least of her worries. She had a splenic artery injury....spleen removed. A liver lac - repaired, her pancreas was torn in half - the head removed. Her brain was herniating - craniotomy done.....pupil back to semi-normal after that........etc. This poor little girl has a long road ahead of her. I hope she makes it through the night. We really worked hard to keep her alive. Amd I hope that if she is alive that she has normal brain function.

The hard part was receiving her mom in the ER after we got out of surgery. Mom looks ok. She lost her husband or boyfriend already on scene. Hopefully she won't lose two of her kids too. Really sad. And is it bad that I really can't wait to get back to work tomorrow to see how everyone is? I guess that means that the job is right for me.

Side note - I pulled my first chest tube today. Simple but cool. It's the small victories. Oh and I saw brain surgery. The brain really does look gelatinous.

Exhausted......back at it at 4:30 am!! Night night.

Trauma

Things I don't like about trauma: getting up at 4:30am for the first 3 weeks

Things I do like about trauma: everything else!

Parents do the darndest things......

Like......have sex in the shower in the hospital room where their 6yo is currently residing. Nurse walked in on it. No joke.

Like......wonder what is wrong with their baby when we get meconium tests back from the baby that are positive for meth and pot and opiates.

Like......tell their kid that they are fat because they took steroids during pregnancy.....not because they drink 4 liters of soda a day.

Like.......bring one of their different 6 kids into the ER EVERY NIGHT for something different. Mind you some of thes "kids" are married and have kids of their own. Last night the one daughter thought that she had passed a tape worm. It is a long, crazy story.....and I mean crazy. She doesn't understand why she poops only every 2 weeks, but the tracks all over her arms tell me why (this is the daughter). Oh and mom's other kid needs a note for school so that he can take longer to write in class because his hand cramped up today while writing. No joke. These are dire emergencies people.

I'm sure I will have more to add to this. I have more Peds clinic and ER tomorrow.

For realsies.......

Before I go into my writing....you should take a gander at the newly added Mr.T quote of the day down on your left. Pure wisdom people. Also some good news for me. I found out that I will be in the Pacific NW for the rest of my rotations (except internal med. not sure where they are sending me for that yet). So either Portland or Seattle for me! Woohoo! That will certainly make things easier for me being close to my family and friends.

So many days on your rotations you feel like a student. There are simple questions that you will get asked by a patient or your preceptor that most times you THINK you know the answer to but aren't really sure. Then you check, verify that you were correct or missing something then relay the info to the patient. Then there are these little moments where you can answer a question with authority and know with confidence. It is these little moments where you actually feel like a practitioner. I think that first moment happened for me last rotation and is happening more and more this rotation. Then you will have a preceptor ask you a simple question like "what is pediatric dosing for Tylenol" I should know this off of the top of my head, but I have very little experience thus far with treating kids (which I will remedy this week). It takes only one little thing like that to remind you that you are a student and that you have so much to learn still.

I think about being done with rotations and is both excites and scares me. Exciting because I look forward to having more of a life and actually having a paycheck. Scary because there are great things that I learn every day that remind me the value that only comes with experience.

For those of you that aren't a PA student, the rest of this may get boring.

So some tidbits for you '11ers.

ALWAYS remove a baby's diaper. We found a gigantic abscess on this baby. She was septic and parents were presenting her as a cough and fever. Not sure if she made it or not.

Things not to miss on a baby's bootie. Petechiae.....could mean meningiococcus. Redness around belly button or umbilical cord (at 2-3 days usually. Pus from cord to) Could mean omphalitis (will kill a baby). A sacral dimple or sacral pit.....could indicate a neural tube defect.

You can give any age Tylenol, but can only start giving Motrin at 6 months.

You can give Zofran during pregnancy.

You can hear fetal heart tones at 12 weeks.

First time mom should feel baby kicking at 20 weeks......veteran mom might feel it sooner.

Later in pregnancy mom should count fetal movement. Baby should move 10 times in 2 hours. All 10 of those times can be right on top of each other, but it should be at least 10 times.

If someone comes in with a really painful sprain or break in their ankle, always palpate the up the leg to the fibular head. If they are tender here, get an x-ray. They may have a maisoneux (sp?) fracture. This fracture is not really treated anyway, it just means that there was enough twisting force that the ligaments between the tibia and fibula have separated and will need a couple of screws put in, even if there is no break in the ankle.

OH and a GREAT one!!!! Totally learn the physical exam for malingering for people with "back pain" aka drug seekers. Here is is in a nut shell. You have them lie flat on their back and you hold the backs of both ankles in your hands. Then you ask them to raise either foot (do one at a time). If they have true pain and are trying to lift their leg, they will push with the other leg in your hand for leverage. If no push, they are full of it. I did it tonight on a known case (she found out that if you get a tooth pulled they give you 6 Lortabs........she's all out of teeth now.....seriously). Anyway, I did it on her and it worked like a charm!! Through all of her moaning and screaming, and carrying on, she put on a show when trying to lift each leg, but absolutely did not try to use the other foot to push off with. I like those small victories. :-)

Hope and heartbreak.....

This week has been full of highs and lows of the human condition. I have been working really long hours this week because I had the flu last week and feel like I was slacking. There have been highs this week in helping to bring new babies into this world, helping soon to be moms come together as a group to become "team members" in a sense in their pre-natal care. It was a pretty cool group and I was happy to see its inception at this institution. "Centered" prenatal care has been studied and shown to end up in fewer premature births and healthier babies. Who knew?

And the lows. One of the first babies that I helped deliver was brought into the ER not breathing. The baby was taking breaths really only when stimulated and would kind of grunt, and then scream for a bit, and then stop again. Mom was furious that we "weren't doing anything" when we were doing everything that we could to stimulate baby and get all of the labs going. Mom even hit one of the nurses. Here is where it gets hard to be diplomatic. Baby has a partial cleft palate and I suspect a neural tube defect d/t the sacral pit (which I observed at delivery). Mom tested positive several times throughout pregnancy for drugs and alcohol and cannot understand what is wrong with her kid, and is furious because she thinks that we don't know anything and aren't doing anything. Very frustrating when a mom says to you "What is wrong with her, why is she not breathing?!" and you want to shout at her that if she actually gave a shit about her she wouldn't have done drugs during her pregnancy and that it is likely her fault that her kid has birth defects and is in trouble now. Baby had to be flown somewhere that has a NICU.

And tonight.....I had a pre-teen in that had severe abdominal pain. Foster mom says that she has had abdominal pain for about 2 months but that today it is worse, she is concerned about an ulcer. Kid is very histrionic and a poor historian.....everyone warns me that she has "a history". I love and hate cases like this. One because I don't like to go in jaded. 2, because I make it a point, jaded or not to work them up like everyone else, even when everyone else writes them off.....which it sounds like a couple other people did today. A high white count and a growing fever tell me that there is something wrong. Her pains everywhere aren't as reliable. She is saying that her tummy hurts but points to her vagina, then it is her flank, then it is upper quadrants. I decide to get a CT, just to be safe, but am thinking that maybe she has a UTI. Looks like she has free fluid in her abdomen and perhaps an abscess. Dx. appendicitis vs. PID. AND PID could be likely because the child has a history of being raped. So then there is a lengthy discussion between me and the foster mom about doing an exam to check for cervical motion tenderness. We don't want to traumatize her anymore than she already has been. So I suggest to the mom that we are going to operate and put her under anyway and approach things the same way, so why don't we talk to the hospital that she will be going to and suggest that they make all appropriate checks and swabs and such when she is under anesthesia. Mom thought that was a great idea. This poor kid literally needed hand holding and does not trust people, especially adults very much. I don't blame her. Her mom was a drunk and an addict, allowed her to be raped, and killed her 2 year old brother and drove around (with this little girl in the car) with the dead little boy in the trunk of her car for months. I spent about 3 hours with her explaining everything and reassuring her, talking to her, and hopefully helping her. She asked me if I would come with her to the other hospital because she was scared that they wouldn't take good care of her like I was. That was sweet and really flattering. I told her that I had to stay here to work, but that she should come visit me when she got better. It broke my heart. That poor sweet girl has a very long rocky road ahead of her. I wish only the best for her. At least, for my part, I feel like she could trust me for those few hours, and that there are people that want to help her, even if all I can do is take away her tummy pain.

Hoohah...

So I scrubbed in on gyn surgery this morning, and it was a beatuiful thing. Except for the nurse anesthetist, the OR was all women. That was pretty cool. I like the OB/GYN's, they are really good about letting me do stuff. Like today, I have never done an endometrial biopsy.....she was like, "It's easy, I'll walk you through it." Pretty cool. They are the same way during birth, they make sure I get my hand in there and feel what they are feeling. P.S. women.....gyn surgery looks kind of brutal. Avoid it if possible. 5 hours of surgery today and I was going to spend some time in the ER this evening, but I am a disgusting sneezy mess. At least I got some gym time in today. I think I am spiking a fever now though, so I decided to stay in and go to bed early. I want to be ready for tomorrow.

Tomorrow I am scrubbing into some foot surgeries then prenatal clinic in the afternoon. Cool thing is that the anesthetist is going to let me do the intubations tomorrow. I think that I need more practice before my trauma rotation when I will have to do them under pressure. I have only done one under pressure right now. It was fine but a little stressful.

Small goals....

Did a couple of surgeries this morning. Nothing major although we took this HUGE lipoma out of this chick's abdomen. It was cool, she was only sedated, so she would start squirming when we were getting deeper into her abdomen.....I am used to people being paralyzed and intubated.....that was different. Nothing more local didn't remedy though.

After morning surgery, spent an hour and a half in the gym....that felt great! I have missed the gym so much, and man am I out of shape! It feels nice to have that good kind of hurt back.

Decided that I would spend some time in the ER tonight. Right after I got there a blizzard started....no joke, can't see in front of you, white-out conditions. I though for sure that we were going to get some car wrecks in......the roads are completely black ice now.

Today was broken finger day in the ER. 3 of them. I got to practice splinting, so that is good. One cool thing is that I was dreading seeing the "depression" in room 1, but it turned out great. We were really slow so I actually spent almost an hour talking to this guy and his wife. He just started dialysis a few weeks ago and is really anxious and depressed....which is common. We talked about what he is doing about it and about positive strategies that he can take to start living his life and being an active participant in it rather than feeling like all of these things are happening to him.We talked about making little changes one at a time. I think that a lot of providers get so caught up that everyone needs to completely change their diet and exercise x number of times a week, etc....that they don't realize that all of that is too overwhelming for a patient. I say pick one thing, like...."Do you drink soda?" The answer is yes, so I say, why don't we start with cutting out the soda and substituting it for water (preferably) or unsweetened tea. Let's do that for 2 weeks and when that is a habit, we will move onto something else. That way, it is manageable. There aren't a ton of things to keep track of. It is one thing - no soda. Then when they do that, it gives them a small sense of accomplishment. It makes a goal that they have actually attained, and then the other goals may seem attainable too. Make sense?

Decided to go home now as it looks like we might have a hot appy brewing for surgery in the morning and I don't want to miss out on that!

Hopefully people will stay off of the roads tonight. I nearly killed myself in the 100 yards going home.

SO a lot of things have happened since I have been here. This rotation is great. My preceptor is awesome and very knowledgeable. I have already worked with some great people and saw some amazing things. I got to scrub in on my first c-section last night. Teenager with child number 3. Very difficult c-section, thought baby might not make it....but the strong little girl pulled through!! Got to scrub in on another one today. This one went much smoother. I definitely don't want a c-section! They are brutal! Some people I think are skeptical of me as an outsider, but seem to be fine with me once they see that I am here to help. Everyone is really nice. I am learning a ton!!

On a somber note, I accidentally stuck myself today. Bummer. In 12 years working with blood, I have never stuck myself. I am not too, too worried, but I will feel better once all of the tests are back re-confirming that all is well. After zoning out for a few, I went on with my day and powered through. No use in me making myself useless for the rest of the day and taking away from anything else I can learn. I did learn what never to do again when doing a paracentesis....that is the big lesson for the day!

I miss Blue River....

I had a blast in Blue River, learned a lot, and was really spoiled with a great place to stay and beautiful surroundings. The drive through Montana was absolutely breathtaking.....I was excited!

Then there is Browning......

Here is a rundown of the day so far......7 hour drive...get to the hospital to pick up my keys. Security takes an hour to answer their pages (God forbid they actually needed security in the ER). FINALLY get my keys and am given a map with no street names.......so after wandering somewhat aimlessly I find my detination, start unloading the car. There is a bed in the front room and one in the bedroom. The one in the bedroom has sheets on it that literally lok like someone has shook dirt inside of them....ew. So I decide on the front room....thank godness I brought my own sheets. So I go to take a much needed shower, pull the little thing up ti activate the shower, and it pulls right out! So, I have to take a bath in a tub that I don't want to sit in.

I have decided to give up drinking on this rotation and get back into shape, but after this day, I decide that when I go to the grocery store I am going to get some wine. I go to get groceries and there is almost NO fresh produce. I mean it was limited. So I picked out what I could. AND there was no fresh chicken!!! What?! what kind of grocery store doesn't have chicken. So I reluctantly bought some frozen (partially freezer burned) chicken, some other things including a $4.50 loaf of bread. That's fine. I'll go to Cut Bank later in the week. I finally get home and go to unpack and have a glass of wine and....no opener. That about sums it up.

Later though, one of the nurses from the hospital that shares a hallway with me knocks on my door to ask if I need anything. I ask if she has a bottle opener. She gives me one, and then as we are talking, she procedds to tell me that she is getting over swine flu.

Good times.

Hopefully tomorrow will be a better day!