Time for the ER!

Well, I'm all done in urgent care, and after a refreshing weekend at home, it's time to start in the ER as the second part of my emergency medicine rotation! My first shift is 8am-6pm tomorrow, so that's pretty normal, but then I have some night ones (5pm-3am) that should be pretty interesting. I've always been a morning person, and my productivity and attention span definitely dwindles at night, so hopefully I'll be able to reset my internal clock for a few days!

My last couple of shifts in the urgent care were great! I got to see a couple interesting things, and still got to manage some more "typical" urgent care cases. I got to sew my first face - a woman had fallen in her bathroom that morning, and had a 1.5-inch laceration through her eyebrow that I got to stitch up! It turned out great, and she was very happy with my work, which is always nice.

Something else that was pretty satisfying was correctly diagnosing a couple of different skin rashes - a lot of them look the same, and most urgent care/ER/primary care docs who see rashes just try to throw a steroid cream at it and hope it goes away, because they can't tell what it is. But! I recognized two different rashes that I learned about in school, which was pretty awesome. It's definitely rewarding to realize that something you studied in school paid off!

Other than those cases, there wasn't too much excitement in the urgent care last week. I'll post an update tomorrow on how my first ER day goes - I'll be with a PA, and I've heard that they tend to see more urgent care-type cases (at least at this hospital), so it might be more of the same things I've already seen. The remainder of my shifts in the ER are with doctors, though, so I will definitely get to see some trauma and more life-threatening things. Part of me is excited for it, but I'm also definitely a little scared! I'm sure no one will let me do anything that matters too much, which is reassuring at least. I'll post an update tomorrow!

Lots of suturing, and a weekend shift!

Sorry it's been so long since the last update! Like everything else, even urgent care gets routine after a while. Plus, my schedule has been pretty sporadic, so there never feels like a good time to write a post.

This past week wasn't too exciting, really, but I did get to do a lot of suturing! On Monday, I got to sew up a woman's arm in four places after she got bit by a dog. Fun fact: dog bites are way less likely to get infected (3-5%) than cat bites (70%) and human bites (80%)! So even though your gut might tell you that sewing up a bite wound is wrong, it's most likely going to be fine if it was a dog that had all its shots. Anyway, that woman got 11 stitches. Right after she left, a man came in after getting sliced in the arm with a piece of sheet metal at work, and he got 8 stitches from me. My preceptor let me do everything - cleaning out the wound, numbing the area, sterilizing the area, and sewing it up! Both patients were also super nice, and easy to talk to, which is good because the whole thing probably took me 45 minutes for the woman and 30 for the man.

Other than that, I've seen a lot of foot/ankle/knee pain this week, so I'm getting pretty good at evaluating that, and remembering all the "special tests" for the knee to figure out which ligament is sprained. We also saw a lot of kids coming in with a "boxer's fracture" (a break in the 4th or 5th metacarpal bone - the hand bones below the pinky and ring fingers) from punching walls! I think we saw three in the same day.

There definitely seem to be themes on any given day - so far, there's been corneal abrasion day, diffuse knee pain with no prior injury (AKA attention-seeking...or a DVT) day, upper respiratory infection day, etc. I worked yesterday, and weekends are definitely much slower than weekdays, which surprised me. I thought people would be more likely to come in on the weekend because they wouldn't have work or other obligations, but apparently not! Over eight hours yesterday (10am-6pm), we only saw 10 people. For reference, on a regular 12-hour day during the week, we usually see 20-24. So, yesterday was pretty slow. Luckily, I have my own computer and bring books to study with, so I never feel like my time is wasted! Plus, everyone that works at the urgent care is nice and fun to hang out with.

I'm working again today from 10am-6pm, and then two more twelve-hour shifts on Tuesday and Thursday. It's not a bad life! Then, next week I start in the actual ER, and I still don't know my schedule for that. I've heard that most people use the ER as an urgent care, so it might not be very different than what I've already seen. I may get to see some major traumas or chest pain/stroke patients though, so it should definitely be a learning experience!

Emergency Medicine is a crazy ride!

My emergency medicine rotation started this week, and it has been crazy! My schedule is a little sporadic - I have three or four 12-hour shifts each week. For the first three weeks of my rotation I'm at an Urgent Care center and all of my shifts are 10 a.m. to 10 p.m., and the last two weeks will be in the actual Emergency Department in a hospital in downtown Pittsburgh.

So, this week I've already worked two 12-hour shifts, and have today off, which I desperately needed. Twelve hours, plus the never-accounted-for extra time at the end of the day for finishing paperwork and getting those last patients out, plus a 25-30 minute commute, is much more taxing than my last rotation!

The Urgent Care center I'm at right now is really great for learning because there's only ever one doctor there, so I just work with the doctor. That means I get to see more or less all of the patients that come through, and it can be a lot! The last two days, I think we had about 20-24 patients per 12-hour shift. Since it's Urgent Care and not an ER, I haven't seen anything too stressful or life-threatening, though we did have to send some people with chest pain over to the actual ER for further evaluation. I have seen plenty of corneal abrasions, ankle sprains/fractures, finger fractures, finger lacerations, a few cases of vertigo, and some abdominal pain. The doctors that work there are good about letting students do things, so I've done a bunch of injections (just tetanus boosters for people with cuts or burns), some suturing, and some eye staining/examination for the people with corneal abrasions. I've always loved eyes, and I finally got to use the slit lamp - the machine used by eye doctors - and it was so cool!!

I have noticed that the doctors here are more brusque than the other doctors I've worked with, and I'm not sure if that's the nature of medicine in a city, or just the nature of the typical ER doctor. They're still nice, but way more fast-paced and serious. Also, a LOT more tests and procedures are ordered here than would have been ordered in a place like Kentucky. The doctor I was working with on Monday told me that patient satisfaction is really important, and a lot of patients don't really care if a test is necessary or not, but will feel better if more is done. So...for example, a younger guy came in on Monday with a cough and sore throat...that had only started about four hours before he came in. It wasn't anything out of the ordinary for him, and his physical exam was fine. In Kentucky, he would have been told that he had a cold and it would clear up in a few days, and to take over-the-counter decongestants and cough medicine if he wanted. In Pittsburgh.....he got a chest X-ray and an inhaler to take home, and a note to get out of work for the afternoon. Talk about the rising costs of healthcare!!

But, I love the nature of Urgent Care. Lots of procedures, and most things are pretty quick fixes that leave people happy! Also, it's not super stressful because, like I said before, nothing is life-threatening. I'll get to see that in a couple of weeks, and I'll be glad to have that experience too, but for now I am perfectly happy diagnosing fractures and giving tetanus shots. I also love driving back into Pittsburgh at night - the skyline is so beautiful, and the city feels alive! I'm definitely glad to be back here. :)

All done in Kentucky!

Well, today was my last day of family practice in Kentucky! It was actually a pretty busy day in the clinic, so that was good. Also, everyone at the clinic got me a cake! They also said they were all going to miss having me around, so that was really nice to hear. I like the clinic and the people who work there a lot, and I really did have a great time here. I'm sad to leave, but also excited to get back to Pittsburgh and to start my ER rotation!

Today, there were a lot of procedures, but nothing particularly exciting. I did a bunch of trigger point injections into sore muscles, and also did two punch biopsies of moles on someone's neck and then sewed them up so they would make prettier scars. It was good that I got to practice both suturing and doing a pelvic exam and Pap smear (yesterday) recently, since I'm sure those are two things I'll be doing fairly frequently in the ER. Earlier this week was also busy, but there wasn't anything that was super exciting. I did some knee injections for a couple of people, and saw some rare(r) conditions like gout and shingles, but that was about it.

As of right now, my car is 90% packed, so all I have to do in the morning is put the last two bags in my car and I'm good to go! I'm planning to leave pretty early so I can beat afternoon Pittsburgh traffic through the tunnel and into the city. It should be a beautiful drive, and there will be nice weather, so that's exciting!

Getting ready to start my last week down south!

Not too much has been happening at the clinic, but I figured I should at least post something since I haven't in about a week! This past week was really fairly slow, and I think I was only actually at the clinic for about 28 hours total. Tuesday and Thursday were long 12-hour days, Monday was a half-day, and I didn't have to go in on Wednesday or Friday! Not bad...I could get used to the primary care lifestyle. :)

Last week was mostly regular check-up visits - there weren't even that many procedures. I did some trigger point injections into sore back/neck muscles for a few people, and cut off a skin tag or two, but that's about it. There was one pretty remarkable patient that came in on Thursday, though: she hadn't been to a doctor in about four years, except for one brief visit to our clinic back in March where she got some labs drawn but nothing else. She was complaining of fatigue, headaches, significant weight gain despite good diet and exercise, constipation, being cold all the time, trouble with her memory, hair being dry and falling out, irregular periods... pretty much all of the textbook symptoms of hypothyroidism. Turns out, she had been diagnosed with Hashimoto's thyroiditis when her son was born...11 years ago...and was never on medication for it. In Hashimoto's thyroiditis, the thyroid gets all inflamed and secretes too much thyroid hormone for a short time, but then the thyroid gets burnt out and can't produce enough thyroid hormone for normal function anymore - hence the resulting hypothyroidism like this patient was experiencing. Hypothyroidism is both miserable and potentially deadly for the patient, so it was good that this patient came in! The way you officially diagnose hypothyroidism is by checking a thyroid-stimulating hormone (TSH) level - if it's high, that means that the thyroid isn't producing enough thyroid hormone, so the brain is "stimulating" it to make more because it thinks the body needs it. Normal levels are typically between 0.5 and 4.5 mIU/L, depending on the laboratory and the guidelines you use. Turns out, her TSH level had been checked when she was in the clinic in March, and it was...are you ready? 29.4!!! This is absolutely unheard of, and it's amazing that she was still functioning at all with levels that high.

Anyway, that was pretty much the only excitement at the clinic last week. This coming week will probably be more of the same. My last day is Thursday, and I head back up to Pittsburgh on Friday morning! I'm excited to be back in Pittsburgh with some of my friends from school, and to see what medicine is like in a city environment. My next rotation is part ER, part urgent care...so the entire experience will be basically the complete opposite of what I've been enjoying in Kentucky! I'm looking forward to it, though, and I think it will be a good experience.

Procedures galore!

Well, life at the clinic hasn't been too thrilling in the past week, but I thought I'd write a short update anyway! As I've said before, most of my day consists of doing the history and physical on people who are just coming in for their three-month checkups for the holy trinity of primary care (at least in the southeastern U.S.): high blood pressure, high cholesterol, and type II diabetes. Most people are really nice, and I end up spending about 30% of the time I'm in the room just talking to them about non-medical things. And, occasionally, we do cool procedures!

Something that was a slight frustration this week was the number of pain medication-seeking patients we saw yesterday. My preceptor said that, for some reason, there seem to be days when everyone is coming in with "back pain...just everywhere, I don't know what caused it" and seems to know exactly what kind of pain medication they "need" and in what precise dose. I'm pretty gullible, and I always want to believe the patient, but even I know that those are red flags for abuse. My feelings about these patients are pretty complicated... I usually talk to them and sympathize with them, then let my preceptor tell them she's not going to give them anything stronger than Tylenol (unless, of course, she thinks they have legitimate pain). I just hope that I don't get too jaded, like a lot of practitioners, and write people off without listening to them.

Anyway, I got to see and do some pretty cool procedures this week! Earlier in the week, we had a patient come in with an injury he got at work (in an auto body shop) - apparently, something exploded and he had all these shards of steel embedded in his hands and arms. He had already removed a piece from his forehead and another one from his forearm at home (!!), but there was a persistent one right above a tendon in his hand that he wanted a doctor to take out. He knew it was there because he held a magnet over his hand and could see the skin tenting a little bit over the knuckle. So, my preceptor dug these tiny, tiny shards out of the man's hand, bandaged him up, and then he went right back to work. People in Kentucky are tough, and they work hard!

Another cool, but unexpectedly gross, procedure this week was taking off a man's ingrown toenail. Apparently, he had dropped some wood on it when he was splitting the wood in his backyard a few months ago, and the nail had broken off about halfway down and had grown back all ingrown and painful. I had never seen a toenail removal before and didn't really know what was involved, but I was feeling tough - I did, after all, just finish my surgery rotation! But I wasn't really prepared for this... my preceptor started by numbing the entire toe from the base, so the numbing medicine would get in the nerve and numb underneath the nail bed. Even watching her force 10 mL of lidocaine into a toe was painful, because there's not a lot of extra fat or room in people's toes, so it looked really swollen and even more painful before the toenail even came off. She also had the patient soak his foot so the nail was nice and soft ... then, she cut down the one side of the nail, and used a pair of hemostats (fancy surgery clamps) to grab the edge of the toenail, then rolled the clamps across his toe to pull the nail off. Gross!! And very bloody! Luckily, the patient was numb and didn't feel a thing.

Finally, on Tuesday I got to do an entire incision and drainage of an infected sebaceous cyst all by myself! My preceptor asked me if I had ever done one before, and I told her I had done a couple at my last rotation. We were really busy at the clinic, so she just showed me where all the supplies were and then told me to go do it. At first I was really nervous, but the procedure isn't actually that hard - just numb all around the area by injecting lidocaine, then slice into the infected area, push all the infected yucky stuff out, then pack the wound and dress it. Kinda gross, but it's really satisfying to drain all of that nasty stuff out and know that the patient is going to feel so much better when it's over. Anyway, I did it, and called my preceptor in to check my work before I dressed the wound and let the patient leave, and she said I did a really good job! There was another one today, and she let me do that one too since I did such a good job earlier in the week.

I'm looking forward to this weekend to relax - for some reason, this week seemed really long, even though it wasn't. I'm taking my general exam for the end of the rotation tomorrow, and then hopefully exploring another nearby state park and just getting some assignments done for school! It should be a nice, relaxing weekend!

"What's a carb?"

The past week or so has been pretty busy, which is why I haven't written anything in a while! Actually, I guess I haven't written since the first day of this rotation....sorry! Even though I'm in family practice, the hours are fairly long and I just get tired by the time I get home and do everything I need to do for school. Most visits are pretty routine--three-month checkups for chronic conditions and medication refills. Something I have been enjoying is getting to talk to the patients. My preceptor always sends me in first to get a feel for how the patient is doing, and if they have any other issues besides their chronic conditions and needing more pills. All of the patients here have been really friendly, and seem to enjoy talking to me. I think a big part of this might be that I go in there without a computer in front of me, so I'm actually looking at the patient and really listening to them. My preceptor, and other providers at the clinic, are always staring at their computers and just going through the checklists. While this has its benefits, like standardizing documentation and making sure every pertinent question is asked, I can tell that it definitely makes patients feel alienated and ignored. So, I think they appreciate someone taking the time to sit at their level, without a computer, and finding out how they're feeling.

One thing I don't like so much is that practically every patient will look a little confused when I start talking, and eventually they ask me where I'm from. My lack of a Southern drawl is pretty obvious in this town, and people always ask where I'm from, what I'm doing here, and if I think they're a hillbilly. I've had people tell me I must be rich because of my accent and the fact that I'm from "up North", and that my accent sounds "proper" so I must think everyone in the town is an idiot. This is all, of course, about as far from the truth as you can get. The people in this town have hard lives, and I have an incredible amount of respect for them. I don't like that people assume that just because I talk differently, I've already judged them and think less of them. But! I still really like it here, but it's definitely interesting to experience life as a very obvious outsider.

Last Friday, there was a festival downtown to commemorate the anniversary of the founding of the town. We went down for the morning and set up a table to check people's hemoglobin A1C levels (basically an average blood sugar level over the past three months) for free, so they could know if their diabetes was controlled, or find out if they had diabetes in the first place. At least 80% of people that we see in the clinic are diabetic, and it's really sad because a lot of them don't control it and have pretty bad end-organ damage, meaning that they're going blind, entering kidney failure, or losing sensation in their feet. What I didn't know was that most people really just do not know what diabetes is, how to prevent it in the first place, and how to control it...and they really do want the information, but have never gotten it. When we were at this table, there were so many people who came up and wanted us to tell them all about diabetes, how to control it, what to eat, how to cook healthy meals, etc. It was kind of nice to see people who were actively interested in their health and be able to help them out! And yes, people really did ask us, "What's a carb?" I guess I just took it for granted that I know the basics of nutrition, and while I'm not an expert by any means, I know what's good and what's bad. I really think that some people in this part of the country just don't know why certain things are bad, and might not ever be told that certain foods are bad for them. It was nice to be able to give people information that will be helpful, and hopefully prevent them from having to be in the clinic here so often!

I haven't done many cool procedures in the past week, just a couple joint injections here and there. But, I did diagnose a heart murmur on just a basic visit! It's nothing serious for the patient, but it was really cool for me that I could hear it. I told my preceptor, and she listened and agreed with me! I'm also getting better at remembering everything from our Physical Diagnosis class and doing a really good physical exam...it's something I was worried about, since I never had to check anything beyond the pelvis/abdomen the entire time. But everything is coming back to me, and I'm really enjoying primary care. I know I've said this every time, but I really could see myself working in an area like this. As much as I love the OR, I think talking to patients, managing their chronic conditions, and hopefully preventing the development of those chronic conditions is much more rewarding. :)