Patient allergies: SIMVASTATIN, DILTIAZEM, PIZZA, OXYCODONE… — Seen in the last admission note for one of my patients. What a tragedy! Everybody needs a little pizza sometimes…
This just happened to me when I tried to restart my patient’s shrieking IV pump after they bent their arm and occluded it.
RN: “Let me give you a piece of advice! You done gon’ touch a nurse’s pump on them and you gon’ get it! Thas real talk!”
Why, thank you ma’am. I only spent 2 years fixing shrieking pumps as a CNA, much to the delight of the 40 nurses I worked with and thousands of patients. That skill does not require nursing school and the NCLEX, nor am I going to kill your patient by hitting the restart button on a fluid that already was running that I myself ordered. Sheesh.
I think it’s surprising that until this week, I had never ever worked with a PA-C during my 8 months of clinical rotations. So naturally I was excited to FINALLY have one as a preceptor during some of my ED rotation.
The verdict? I’ve been moderately disappointed. I know one person does not represent all the PAs out there, and this preceptor is not a bad person or a bad provider. He just doesn’t go out of his way to teach me much. Important findings from the radiologist will come his way via telephone and he’ll keep me on the down low. There is not much discussion of the assessment and plan. I’ll be ready to see more patients, and they’ll be brought back but he won’t tell me and will go see them on his own. I have a hard time butting my way into his time and the other patients he’s seeing and asking for more, so usually if he seems busy I’ll be checking uptodate, only to see he’s started watching sports on the computer. So yes, the time to teach me does exist.
It’s hard because there are residents on the computer beside me who I know would be excellent teachers but they’re not my “assigned” preceptor and I don’t want to hurt anyone’s feelings.
I’m just ranting I guess, but I only have a few more precious months of rotations to learn, and let’s me honest, I feel DUMB AS HELL and I’m so tired of lukewarm preceptors who don’t want to teach… I’ve had a few at this point.
On a positive note, the most awesome nurse found me yesterday and declared that she had a Foley to insert, and would the student like to do it? YES PLEASE!
Today I was assigned to work with the nurses in the trauma resuscitation bays. The same place where the RT and I coded the guy the other day. My classmates had told me that the days they had spent there were pretty mellow so I wasn’t expecting anything too crazy. Yeah, I was wrong.
7:30am: We get a call that EMS is bringing in a man who had been acting strangely the past few days then went down and suddenly started seizing this morning.
7:35am: The man arrives. We’re told he only speaks Spanish, but that doesn’t really matter because his Glasgow coma scale is about 4. I get his chest electrodes on while the nurses get IVs in. His BP is 240/129. I check his glucose, which the machine can’t read because it’s > 600. The resident decides he needs a rapid sequence intubation. The nurses push propofol and Fentanyl and a bunch of other things I can’t remember. As soon as the tube is in he’s rushed to CT. The resident suspects he’s had a hemorrhagic stroke from hypertension.
7:45am: The CT results are back. There’s no hemorrhage, but something weirder. He’s got air spots in his brain. The differential is now ruptured teratoma vs neurocysticercosis (pork tapeworm in the brain). We had to lower the sedation because his BP was dropping too fast (and we learned in PA school if you lower the BP too much in a hypertensive emergency you can cause ischemia to the brain) but now he’s fighting the tube and trying to get off the stretcher. We increase the sedation and hope for the best. His family arrives as well as an interpreter. I know enough Spanish at this point to understand everything they say, and I hear the man’s brother asking him if he can see Jesus while he stands at his side and strokes his head.
8:15am: EMS brings in another patient with possible stroke, with onset 45 minutes ago. The clock is ticking for administration of TPA. He now has no neurologic deficits and the resident thinks he may have had a TIA instead. The patient says he has no other health problems but I take one look at his edema and dyspnea and the LVH I see on his EKG and I have a feeling he’s got undiagnosed CHF. His lovely wife of 40 years arrives and sits by his side, tearful.
9:00am: EMS brings in a woman from a nursing home who was found unresponsive in her bed and “foaming at the mouth.” She has a history of seizures. She is still unresponsive to commands but cries out “Oh Lord” as we try to get an IV into her uncooperative veins. The resident decides she doesn’t need to be intubated. She gets a sepsis workup, head CT, and cardiac enzymes. A nursing student shows me how to insert a Foley into the patient, and murky urine comes out. It turns out she has a fulminant UTI. After the residents have left, I do my own exam and discover the biggest thyroid goiter I have ever felt.
10:00am: While I am still tending to the woman with the seizure a man who walked in is brought back for dyspnea and hemoptysis. I take a look at his chest x-ray and try to figure out what it is on my own. My first suspicion was tuberculosis, but I learned in Ecuador to look for those lesions in the apex of the lungs and I don’t see anything there. The left side looks like pulmonary edema to me. His heart is enlarged. The official radiology interpretation comes back and I’m right! Woohoo I can finally get the gist of a CXR!
11:00am: While I’m checking the labs on the patients that have already been seen EMS brings in a man with respiratory failure. His wife came in the ambulance with him and is crying at his side while the team tries to resuscitate him. He ends up stabilized on bipap. The RT I worked with the other day comes by and shows me his ABG. Hypercarbia and severe acidosis. He also tells me that the man has end-stage lung cancer. Several hours later, his wife is still at his side, calling family on her cell phone.
2:00pm: An unexpected trauma is brought in by EMS. The man is alert and talking, but is covered in blood. He was involved in a construction accident. I check his BP and it’s stable. I don a mask and face shield and watch as the residents inspect his wounds. He has laceration on his arm down to the muscle. He also has a head laceration literally down to his skull and it’s probably 6-8 inches across. I watch as they search the wound for foreign bodies or skull fractures… or brain I suppose. They cover him back up and run to order imaging. I talk to the man as I help the nurses clean him up. He is taking this surprisingly well. He tells me that his friend was also involved in the accident and is wondering why his friend isn’t here as well, as he was in worse shape than the man. The man tells me he rescued his friend from the rubble and saw he was bleeding out of his ears and nose and then called 911 for the both of them. I exchange a glance with the intern next to me and we both know that this doesn’t sound good. We’re the closest level 1 trauma and the friend should have been brought here. The nurse calls “Doctor, would you please come and look this lab for me?” We both go the computer screen and see a note the nurse has brought up from EMS. It reads: Pt’s friend deceased in accident, unable to revive. Pt is unaware of friend’s death. We swallow and nod our heads. “Your labs look good,” the intern says to the man, “Is your family on their way?”
3:00pm: It’s time for me to go home. I saw a lot of crazy things but I feel ok. I plan to go for a run as soon as I get home, but I’m suddenly wiped and lay down in my bed for a nap. And all I dreamed about was getting IV access.
Apparently I was a white cloud in the MICU because there was NEVER a real code the whole time I was there. A few pseudo-codes and lots of rapid responses, but everything turned out to be fine.
Today I was assigned to work with a respiratory therapist in the ED. He was a really cool guy who actually is interested in critical care and thought about becoming a PA at one point but is now doing some research into additional training for RTs to become a midlevel similar to PAs.
Anyways, there was not much going on. We gave a few nebulizers to asthmatics and shot the breeze for a few hours. We got a call that there was a man with respiratory distress and possible pneumonia who could use some RT help, so we went to his room and played with his oxygen a bit. They decided to move him to a larger resuscitation room so he could get bipap for a while. Right after that, another unexpected trauma from EMS came into the next room who had already coded twice but had been revived. Immediately the whole team of RNs, MDs, and the RT attended to him, cutting off clothes and inserting lines. They switched over his vitals monitoring and then a nurse announced that he didn’t have a pulse.
Suddenly, compressions were started. Pressors were pushed. A defibrillator was attached. I was pushed in to relieve the person giving compressions. Fast and deep! they called. And I put my hands together and pushed just like I had been taught in BLS, to the tune of “Stayin alive.” I really did. I’m not kidding. I needed something to keep me tied down to reality. I started to huff and puff. Giving good compressions is a lot of work, and it was hotter than hell in that resuscitation room. But this man’s life depended on how well we ran this thing, so I kept pushing.
Pulse check! they called a few minutes later… I’ve got a pulse!
WHAT!! I just beated on this man’s chest and now he has a pulse! CRAZY! I stepped back and watched his pulse and pressures climb up on the monitor. Wow.
OK, blog is finally up to date now. Time for real time posts, yayy!
I’m spending the next month in the ED of a HUGE hospital. Like, 1000 beds huge. And the ED is the biggest I have ever seen. There are sections for fast track cases (in and out things like lacerations, ankle sprain, etc), 3 sections for more urgent needs (level 2-3 cases such as chest pain, syncope, etc), a short stay area (for heart attack rule outs and that kind of thing), a level 1/resuscitation area (for people who are really unstable, traumas, etc), and a special area for pediatrics.
This rotation is kind of neat because while I’ll spend the majority of the time in the areas taking care of level 2-3 cases, I’ll also get to spend some time with respiratory therapy and in the resuscitation/level 1 area.
AND this is really crazy but in the 9 months of my clinical rotations I have never EVER once worked with a PA. So I usually feel incredibly stupid as I constantly compare myself and my knowledge to the medical residents I’ve been working with who have about 5 or so extra years of experience on me. But word on the street is that there are quite a few PAs in the ED here so hopefully I will have a better idea of the PA role vs resident or attending role.
I really enjoyed my first day. I’ll have a different preceptor each shift, but I had a really nice MD that I worked with. Always nice to be with someone who will tirelessly teach! And right away I saw my first kidney stone (thank goodness the patient was a nursing student and was absolutely textbook when I took her history!), and then after that a case of chest pain in a young adult (I suspect it was due to palpitations after consuming an energy drink), asthma refractory to outpatient treatment, a sickle cell crisis, and worsening syncope.
We were warned that the ED is a place where you are expected to gather your history, take your focused exam, and be out of the room within 15 minutes. Crazy. I have a really hard time interrupting sweet old people who are telling me how Jesus has changed their life through all of their health problems but now I guess I’ll have to work on my dick attitude and cut people off :-/ Haven’t had to yet though, so let’s cross our fingers that everyone will be cooperative in this effort!
It’s also hard for me to not work up every concern that a patient has. I guess this is why primary care was also difficult for me. I wanted to hear about everything and offer some sort of advice or insight but there’s just not the time… I think I may be destined for the hospital, in the inpatient units, where you can always come back and talk more and the lab is on site!
Nonetheless, I’m excited for the rest of this rotation. I will definitely see a lot of patients and work on my differential. They’re telling us to think about things that could kill a patient for any presenting symptom, so hopefully I can really fine-tune my focused history and exam, presentations, and especially my plan.
Eerie hospital views late at night…
And trust me, at 4am in the call room a plastic mattress covered with questionably clean blankets swiped from the radiology linen room looks might fine.
A novel way to combat drug resistant pathogens. This R2D2-esque device is being used in the MICU as part of a study investing the potential for UV light’s use in sanitizing patient rooms after discharge, especially for patients that tested positive for drug resistant microbes. It may prove to be an important measure in decreasing the transmission of these bugs, as we are quickly running out of antibiotics to fight them with.
And the verdict is that taking 3 months off from real medicine WILL make you rusty in many things. Giving oral presentations on MICU patients with 10 sections to the assessment/plan area of the SOAP note is one of them.
I’m not going to lie, starting this rotation really made me nervous, but I’m really glad that I signed up for it as my second elective. I kind of did it on a whim and a hunch, as I spent several shifts when I was a CNA being floated to various ICUs and I just seemed to like the environment, so I thought maybe I’d like it as PA as well.
The first two weeks were a little bit slow, believe it or not. I was in a smaller hospital, so a lot of the patients really belonged on a step-down unit, which did not exist at this hospital. But after that, the acuity really picked up. I learned a thing or two about mechanical ventilator management and a whole lot about thinking critically and in terms of multiple organ system interactions. I helped put in central lines, did a thoracentesis, watched intubations, ran to rapid response team calls, and saw a code (yes, only one, believe it or not). I also had a really interesting patient who was basically pronounced to be in a persistent vegetative state by the MICU team, neurology, and psychiatry miraculously come back from the land of progressive brain death and talk to his family once again. I also saw one patient who had been in the ICU for over a month finally make it to the general medicine floor.
I took REAL overnight call for the first time ever. Every third night I pulled a 30 hour shift. I usually got about 4 hours of sleep. These were my favorite shifts, because I was with a resident who was awesome and loved to teach. My other two non-call days I came in early to pre-round on my patient, went to rounds, and usually left by 11:00 (whaaat? awesome!).
So, what did I like about working in the MICU? I’ve decided I like thinking about things in terms of physiology and mechanisms. I hate to memorize things “just because.” There always needs to be a reason for me. I like renal issues, cardiology, GI, and pulmonology. I really like working things up, and I don’t like it when there isn’t enough time to think about what needs to be worked up. I like having a smaller number of patients close by that need frequent monitoring. I like a teaching environment where you can bounce ideas off of one another.
I could see myself working in a medical ICU. Either that or maybe as a hospitalist/internal medicine. Not sure if I saw that one coming! Even though I loved working in a hospital as a CNA, I thought I’d end up doing primary care once I was a PA. I guess life is full of surprises!