Psychiatry is improving...slightly

I'm still not loving psychiatry, but it's getting a little better than the first week. My actual preceptor is back from vacation, so that means that my classmate and I (plus two other PA students from another nearby school) get to see more patients and spend more time on the unit, which means that we feel more connected to the patients since we can follow them throughout the entirety of their stay.

The stories are still sad and I've decided that psychiatry is definitely not for me, but at least it's a little better. I was disappointed to learn, though, that my preceptor doesn't really do outpatient treatment much anymore - he does some pediatric psychiatry for a few hours a couple days per week, but it's in a different location and he said that students don't usually go with him to see that. Plus it sounds like it would be even more depressing than what we're seeing with a (primarily) adult and geriatric population!

So, even though almost all of the cases are sad, that doesn't mean they're not fascinating. Listening to people who are delusional can be pretty entertaining at times, and seeing some of the conditions we learn about in school - schizophrenia, borderline personality disorder, paranoid personality disorder, the mania aspect of bipolar disorder, etc. - is really interesting. The sad part is hearing the background stories behind depression/suicide attempts, or hearing how patients have gone undiagnosed or untreated because they don't have insurance or can't afford their medications. Mental health care is really difficult (and probably frustrating) for everyone involved - providers, nurses, and patients alike. I guess it can be rewarding when treatment works, but I still don't think I could ever see myself working in this field.

An underwhelming first week of psychiatry...

This is, technically speaking, the end of the first week of my psychiatry rotation, but I've only spent about six hours actually seeing patients, and all of that has been basically watching the doctor talk to patients. Granted, my actual preceptor is on vacation this week so we're only seeing the covering physician doing his rounds at an inpatient facility, so I'm sure it'll improve once he's back at the end of next week, but as of right now I'm not impressed.

Plus, the drive to get to this rotation is ridiculous. It takes about an hour and 15 minutes to get to the site...it does get pretty as you get into the suburbs, but it gets old. Luckily (I guess), I only had to make the drive three days this week!

The inpatient facility we go to (I say 'we' because one of my classmates is also at the site!) is really more of a holding facility, a sort of in-between for people that can't stay in the ER but either can't find a bed in a long-term inpatient facility or will be cleared to go home after just a few days of observation. This includes a lot of suicide attempts and people who would like to go to rehab for various addictions but can't find a place with an open bed. Those two groups probably comprise 95% of the patient's I've seen so far, and the other few are people from group homes who were violent and got involuntarily committed from their other institution.

As you can imagine, most of the stories you hear from these patients are just awful. It's not exactly an uplifting rotation. I'm hoping that when the actual preceptor gets back from vacation and we get to see some outpatient stuff that it gets a little better. At least in an outpatient setting you can see garden-variety anxiety and depression that is (hopefully) getting better with medication. I have seen some interesting things so far, though...including a (very paranoid) schizophrenic, and a person with borderline personality disorder. So that was interesting to see!

I'm really hoping that this rotation picks up next week. It might take until the week after to get really interesting, though, since the main preceptor doesn't get back until Thursday. But I'll be sure to post if something interesting does come up!

Goodbye, Montana!

Tonight is my last night in Montana! I am definitely sad to be leaving this rotation and this town, but I'm also really excited to get back to Pittsburgh and see my friends from school (and be able to shop in any of a number of big stores within five minutes of my apartment!). The nurses from the clinic actually threw me a party on Monday, which was so great!! There was a ton of delicious food, and everyone from both the clinic and the hospital came, which was really nice.

This week was relatively quiet clinic-wise, which was good because I had a lot of packing to do! The most interesting thing we saw was this teenager who came in for "sinus problems" and turned out to have this giant polyp (we think) between his nose and throat. He couldn't breathe through his nose at all, and it had been that way for a month! His CT was amazing to look at - the polyp must have been at least 2-3 inches in diameter, which is a lot of space for something to take up in the back of your throat. Anyway, he obviously got a referral to a specialist in Billings.

I'll really miss it here, especially my preceptor. He always told me to say, when asked where I learned a skill or fact that I learned from him, that I learned it from "that country doctor who was wacky, but wise." He's kind of eccentric, but he's easily the best doctor I've worked with on rotations, and I am truly grateful to have learned from him.

My next (and last!) rotation is back near Pittsburgh, and it's psychiatry! I'm sure I'll have some interesting and/or entertaining stories from that one, so stay tuned!

Winding down in Montana...

Well, believe it or not I only have three days left at the clinic here! Today was my last Saturday clinic day, and it was a busy one. Nothing too exciting, really - just a lot of the same types of things I've been seeing the whole time I've been here. We did have one person come into the ER with a persistent nosebleed, and I got to cauterize it using silver nitrate sticks, so that was cool!

Last week was actually relatively quiet in the clinic. I think it was because the weather finally got a little nicer, up to the 50s (and even low 60s!) most days, so people decided they didn't want to be sick or didn't want to come in. I actually got home by 5:00 twice last week! My previous record was 5:30, so that was pretty exciting.

I don't have much to say beyond that...I will definitely miss it here, though. I had a chance to drive around and explore a little today, and Montana is just beautiful. And the people are so nice! I've learned a ton of medicine here, too, and feel pretty well prepared to be a practitioner myself. Now I just have to make it through one last rotation, a few weeks of review, graduation, and the boards (and the job hunting process), and I will be! :)

Another good week!

This week seemed long, but was ultimately good. Last weekend was absolutely insane, and I was basically over in the hospital or ER all day on both Saturday and Sunday. Then the clinic was crazy on Monday and Tuesday because my preceptor was the only provider there - one was on vacation, and the other was at a conference. Anyway, we were booked more than solid for two days straight, and I ended up being there for about 11 hours both days. On Wednesday I was looking for some relief, since we normally do nursing home rounds on Wednesday mornings. Well, we never made it to the nursing home...my preceptor was on call, and four different people came into the ER throughout the morning. Nothing was too wild, but one person did get sent down to Billings and some others got admitted after an extensive workup. Plus, we had five patients in the hospital and they were all being kind of complicated that morning too! So it was an extremely busy few hours trying to get that all sorted out in time for clinic in the afternoon.

The patient that got sent down to Billings that morning was the most stressful experience I have witnessed yet on rotations...this 1.5-year-old girl was brought to the ER by her mom to have a CT done of her head, since she had happened to hit her head in the same spot three separate times and her mom had noticed she was sleepier than usual lately. Also, she had started to notice these blue spots in the corners of her eyes. So, naturally, she was worried about some kind of bleed and wanted to have it checked out. The best way to do that (that we have available at the hospital here) is a CT. But what 1.5-year-old wants to sit still long enough for a CT? We had to use conscious sedation on her to get her to stay still so the pictures would turn out well enough to interpret. So the nurse puts in the first dose of Versed....no response. The kid is still screaming and squiggling all over. So she gets the second dose...still nothing. Then she gets a dose of a different sedative...still no response. Then she gets another dose of the first sedative, and still no response. They are getting ready to give her another dose of the second sedative when all of a sudden she just drops and stops breathing right there on the CT scanner. Her oxygen saturation dropped to about 76%. Everyone rushed in and started bagging her and pushing the reversal agent. I'm not sure how long it actually took to bring her back, but it felt like an eternity! It's just so unnatural to see a little kid laying so still and unresponsive. Eventually she did come back, but she coughed up a bit and aspirated and was then coughing some more. She was still pretty strung out on the sedatives, and we decided to send her out to a bigger facility. Talk about a stressful morning!

The afternoon and the rest of the week was much more chill. Today was busy, but not bad! Hopefully tomorrow is calm so I can get some things done for school. I'll miss it here when I leave, but I definitely can't wait to have weekends to myself again, and to be near my friends! :)

An interesting week!

First of all, the best news: I got engaged last weekend!! My boyfriend came up to Montana to visit me, and we went skiing, and he had come up with the most amazing proposal that I was not expecting!! I was completely surprised and so, so happy!! :)

This week was full of interesting cases! Well, really just one very interesting case, and some other mildly interesting things. One (male, elderly) patient came in earlier this week, and the reason listed in the computer for his visit was "lump on left breast". Reading that, I thought it was going to be something like a lipoma, cyst, abscess, or some kind of dermatological complaint. So, I go into the room, all ready to take a look at it, tell him what it was and what to do about it, and get out of there in 10 minutes or so. When I get into the room, I start asking the patient about it, and he tells me that it's been there "Oh, for a while" and that he thought it would go away but it didn't, and his wife made him come in today. He said that it's "kinda red" and doesn't bother him really, but it itches sometimes. So, I ask him to pull back his gown so I can take a look, and there is a giant mass the size of my fist on the lower part of his left breast. It's red, lobular, and fixed, and there was nipple retraction...in other words, it looked exactly like a terrible, very advanced breast cancer. I went to get my preceptor after I finished the rest of the exam, and he came in, and was visibly shocked at what he saw. We ordered a CT scan, and it looked even more like cancer on that...and we saw a smaller lesion on his right side as well. We immediately referred him to a general surgeon for a biopsy. We'll see what happens, but it doesn't really look good.

Otherwise, this week was pretty uneventful, though I did see a baby with pyloric stenosis today. That's a condition that's pretty rare, and happens in babies when they have a congenital narrowing of the valve at the end of the stomach where food goes into the small intestine. These babies vomit up basically everything they try to eat, because there's not enough room for the food or formula to get through. They are also constantly hungry and parents report that they are "constipated," though it's really just that not enough is even getting through to be excreted. Anyway, one of the cool (for me to see) physical exam findings for pyloric stenosis is an "olive-shaped mass" in the epigastric area (from the dilation of the end of the stomach from all the pressure of the food not getting through), and this kid had it! It was pretty interesting.

I'm only here for four more weeks, and I'm starting to get a little sad about it. I don't think I would ever want to live here, but the clinic/hospital itself is really nice, and I like the staff a lot - even my eccentric preceptor. I will definitely miss it when I leave!

Quick update!

Hello all! Nothing has been amazingly exciting here, but it's time for an update anyway. We did see a couple cool cases yesterday...one finger dislocation that we pulled back into place, and one guy who had some metal shavings in his eye that we removed! In school you learn that if there's a foreign body in the eye, you make sure the patient is stable and call an ophthalmologist. In Montana...you try to take it out yourself! All we did was numb his eye and then use this metal hook thing to try to pry the small piece of metal out. It worked!

Nothing too interesting has come into the ER recently, either. I haven't been able to do any hands-on stuff like suturing or stapling in a while. But I've been getting lots of experience diagnosing colds, sinus infections, mono, and the flu! And, amazingly, I haven't come down with any of those things (yet!). Every once in a while there's a case that's more interesting clinically, but most of it is pretty simple. I'm starting to feel pretty confident with primary care, since at this point I've had quite a bit of exposure to it! I'm even getting better with little kids, which is nice. I don't think I'll ever want to work in pediatrics, but it's obviously a good skill set to have.

Anyway, this weekend I'm going to try to explore the area a little more, and maybe venture up to Canada! Then next weekend I'm going on a skiing vacation in southern Montana with my boyfriend, who's flying up to visit for a long weekend. I'm sure this next week will fly by!

A good week!

This week was nice and (relatively) laid back. There were some interesting cases, too! Granted, there were a lot of appointments for checkups/medication refills and upper respiratory infections, but we also saw a couple cases of mono and some other things. One patient was particularly interesting...her appointment slot just said she was there for medication refills, but once we were in there talking to her she started talking about how she'd been losing her balance over the past few months. Later, she mentioned that she'd been having some trouble holding lightweight objects (like a piece of paper) in her hands, because her grip "wasn't strong enough." On exam, she had a positive Romberg (balance test), ataxic gait, slightly weakened grip strength, and couldn't perform some of the cerebellar function tests. Needless to say, she got a referral to a neurologist. My preceptor and I both couldn't come up with a good idea behind why she was having these symptoms...we have a few ideas, but nothing seems to fit perfectly. I'm glad I'm here for another 8 weeks still so I'll be able to find out what happens!

And on Thursday, I got to hang out with a radiologist all day. I realize that most normal, non-medical people wouldn't think that's very exciting, but it was! Thursdays are my preceptor's days off, so he sent me out to this other town (90 miles away, or a "hop, skip, and a jump" to Montanans) to learn some radiology skills with the radiologist who reads all the X-rays and CTs from our facility and others. He was so nice and such a great teacher! I learned a lot, and I'm really excited to develop a skill set that most PA students probably don't have the opportunity to develop. Plus, it was nice to drive around Montana a little more. Even though the part of Montana that I'm in (north central) is pretty much flat, it's still beautiful. I'm hoping to explore a little more tomorrow!

Hello from Montana!

I'm so, so sorry I didn't post sooner! I was really busy getting settled in, and then the hours in the clinic this first week were pretty long and demanding, so by the time the day was over I just didn't have it in me to write anything.

So! Let me first explain the setup here. There is a nursing home facility with about 50 residents, a six-bed hospital, a two-bed ER, and a fully functioning clinic all located within the same building. The medical professionals in charge of this facility are one doctor, one PA, and one nurse practitioner. That means they do everything! They are simultaneously internists, pediatricians, gynecologists, ER providers, and long-term care providers. These three people are basically responsible for everything and everyone within a 90-mile radius, because that's how far it is to the nearest larger town. As the only student, this is an amazing opportunity!! Yes, I'm technically here for family practice and pediatrics rotations, but I'm also getting to brush off my ER skills and getting to learn some long-term management skills.

I'm mostly in the clinic, as are the providers. A typical day there lasts from 9 to 5ish, plus then finishing any lingering paperwork, and we see about 12-15 patients per day. I really like this patient load, because it gives you plenty of time to talk to patients and make sure you're really taking care of them well. So far, most visits have been for seasonal sicknesses - flu, sinusitis, bronchitis, etc. - and there are occasional checkups or follow-ups. I see a pretty good mixture of adults and kids, which is good - I have zero knowledge of how to interact with small kids in a medical setting! I think that will definitely be my biggest challenge while I'm here. It's an intricate dance of making sure the child feels comfortable around you so they let you do the exam, and also making sure the parents trust what you're doing and saying. Hopefully I'll be much better at it by the time I leave!

Most clinic visits aren't super exciting, but I have been able to do a fair number of procedure-type stuff in just the first week! I got to staple someone's head after they slipped on ice and fell and hit their head on stairs, and I got to suture a thumb that got sliced open by a carpet cutter at work. I've also done pelvic exams and Pap smears! Really, this rotation is kind of functioning as a review of most rotations I've had so far, plus adding the pediatric element. It's great!

Everyone here, patients and providers alike, is super nice and I think I'll really enjoy being here for the next two months or so. It's definitely a small community, though, and I can't really even go to the grocery store or the post office with that small degree of anonymity that you take for granted in suburban or urban life. Everywhere I go, people know that I'm not from there, and most times they even know that I'm the PA student at the clinic, because they heard one was coming and I don't look familiar! But that's okay, everyone is very welcoming and they seem happy to have me here. :)

Made it to Montana!

I'm all settled in and ready for my combination family practice and pediatrics rotations! The town I'm in is pretty small, and I haven't had much of a chance to explore yet, but I don't think there's much to it. So far I've only gotten a tour of the clinic and hospital, and I've been to the grocery store. The town seems nice, and the people are really friendly! I met a bunch of people on my tour today, even though it's the weekend, and they all seemed really welcoming. I'm excited to start tomorrow! I'll be sure to post an update about my first day. :)

Still in IM...

I'm still doing my internal medicine rotation, and just wanted to check in quickly! I'm not loving the rotation, mostly because I'm pretty frustrated with the lack of care most patients actually receive, and I don't want to rant about it too much in case anyone from my school (or the doctor's office) could happen to find my blog somehow. But, essentially: the office I'm at sees a high volume of patients each day, and that means that the doctor spends about 2-3 minutes with each patient, and really glosses over some things that (in my opinion) should be given more consideration. So! It's up to the students to really talk to the patient and advocate for what they think the patients need, but the doctor can choose to ignore some really glaring things.

I'm honestly pretty disappointed in this rotation. As my preceptor's head nurse said to me today, "This is the rotation where you learn what not to do." My preceptor is a personable guy and pretty friendly, and his patients like him because of this, but they're really not receiving in-depth, quality care. I'm hoping my next rotations in Montana will be different!

A great day in IM!

This rotation is great. Not only are the hours incredibly sparse (this whole week, I will only be there for about 23 hours...), but my preceptor is really nice and a great teacher, and the patients are (mostly) nice and come in for relatively easy appointments. I think my favorite part, though, is just taking a few minutes to talk to people and help them beyond just refilling their medications.

Today, for example, we had a new patient come in who hadn't been to a doctor in over six years, because he "never felt bad." So, when I was asking him the typical questions that you ask a new patient, I inquired about his diet and found that it was awful (fast food, highly processed foods, no fruits/vegetables, lots of carbs, sugary drinks all day every day). He thought he was doing pretty well, and told me he never even thinks about eating more healthily. So...kindly and patiently, I suggested adding more fruits and vegetables in, and also suggested drinking something like a V8 Fusion that tastes pretty good but offers some of the benefits of fruits and vegetables. He said he hates fruits/veggies, so that sounded like a good option, and he was definitely excited to try it. Also, he was already trying to quit smoking, so I encouraged him with that and gave him some tips. We also set up a couple of referrals for problems that would require a specialist. It just felt really good to listen to the problems this patient was presenting with and help him to come up with a plan of action that he was really, truly going to follow. I felt good leaving that room because I knew that a person who had previously hated doctors and was only coming in for an acute complaint had been converted and would start getting preventive screenings and care. So, I was pretty proud of myself!

The rest of our patients today were pretty uneventful. This rotation is pretty relaxed, and we get free food a lot. Even though it's not as exciting as, say, the ER or surgery, I could see myself working in an office setting like this!

First day of internal medicine!

My first day at this rotation went much better than anticipated! I fell right back into the groove and did totally fine at talking to patients. It definitely helped that my preceptor is incredibly laid-back and funny. He's not pretentious or uptight at all, and he seems to treat students like people and not idiots, which is refreshing (even if I still feel like an idiot at times and still, obviously, have a lot to learn!).

He gives us a lot of autonomy, which is both awesome and terrifying. We (me and the two other students) bring patients back, take their vitals, and see them on our own. Then we jot down a brief SOAP note on the back of their intake sheet, and give it to the doctor (or present it briefly if we have time! He moves fast!). Then, he goes in to see them for about one minute, and basically just chats. Most patients are there for their three-month follow-up visits just for medication refills, but I did do one annual physical today. Then, he uses our opinion and our note to dictate the actual note! Seriously, I heard him doing one of mine and it was essentially exactly what I had written down. Even though it's scary to think that I'm essentially having the last word in terms of how a person is doing, it's also good because it makes you actually assume responsibility for the patients, instead of just relying on the fact that someone with more experience is going to go right in after you and double-check. So, it's closer to real life, and I like that.

Oh, and the content of the visits is very similar to family practice - medication refills and urgent care-type stuff like colds, joint or back pain, etc. Nothing I can't handle. :)

Back at it!

Well, after an amazing and much-needed winter break at home with family, I am back in Pittsburgh and ready for my sixth rotation - internal medicine. If I'm being honest, my heart's just not in it right now - I'd rather still be hanging out at home for a few more weeks! I'm hoping that getting back in the routine tomorrow will help.

This rotation should be relatively relaxing compared to my last couple rotations - this whole spring semester, in fact, is going to be much more laid back than the fall, just because of which rotations I have coming up. Internal medicine is really just general practice, but specifically for adults. So, it will be a lot of high blood pressure, high cholesterol, and diabetes, and managing all the medications that come with those. Personally, it's not fascinating to me, but my preceptor is supposed to be really nice and relaxed, so at least the rotation itself will be fun.

I'll actually only be at my rotation for the afternoon tomorrow, but I'll try to post an update about the first day anyway! Here's hoping it's either more exciting than I think it will be, or that my attitude changes with a good night's sleep. :)