Clerkship 6: Surgery

My surgery rotation was back in March 2017.
In short, it was a great rotation. I set it up myself, well, through my program of course. My preceptor is a vascular/general surgeon.
What did I get to do as a student and what did I learn?
I learned how to use laparoscopes, retractors, and suction. I held intestines out of the way and was allowed to close via suturing or stapling as appropriate. I observed robotic surgery. I learned in-office radiofreqency ablation (RFA) therapy for varicose veins. We rounded on pre-op and post-op patients, and also saw them in the office too.

Standing in front of set up for RFA, ultrasound machine in background. 

It was a challenging rotation, but also lots of fun.
Some of the challenges: hospital hoops and tough personalities in the OR. My surgeon was a gem, believe it or not. I made a decision early on, to kill em' with kindness. I wasn't going to let a bad attitude or two steal my joy or detract from my 4 weeks in surgery. And I contacted my clinical coordinator and the issues (hospital hoops)  were quickly resolved.

What was fun? Interacting with patients and anything hands on! I learn best hands on, and  my surgeon was not only talented, but very approachable and we had a good time! Additionally, I met some pretty cool folks in the OR that more than made up for the haters.
I won't be going into surgery but this was a good rotation. Setting up this particular rotation was one of the best things I did in PA school. I worked a lot, and my commute was 45 min or so. There was some pimping, not much, but enough that I reviewed the anatomy, physical exam findings, and surgical techniques for scheduled procedures. Now, we know some surgeries are not scheduled, but I did ok!

Last minute Walgreen run for socks!

There were tons of cholecystectomies and appendectomies as you can imagine. I had my scope skills and my running subcuticular down in no time! Speaking of that, I don't think it helps much to practice lots of suturing. I mean, it doesn't hurt if you have time, but the surgeon will teach you the techniques that he/she uses.
I have prior experience in the OR as a x-ray tech running the C-arm. I wasn't sure if that would be enough for what I was about to see. But, I was up close and personal, with long hours on my feet with a mask on, and glad I had the stomach for it. I assisted in removing tumors, placing feeding tubes, draining abscesses, placing AV fistulas, and assessing patients in the ER with huge inguinal hernias, mesenteric ischemia, and more.
This was definitely a valuable rotation and a great learning experience.

RFA machine

Set up for RFA

Clerkship 5: Elective Rotation

I am a few weeks behind on posting due to my Master's capstone project deadline and catching up on PANCE prep required by my program.

So, my chosen elective was pediatric oncology, but it was not meant to be. My elective rotation was cancelled because a new PA was being trained, and so I could not be accommodated. I consider myself fortunate because I had time to find another rotation. Some of my classmates had very inconvenient last minute changes!

However, I was definitely disappointed because I was so looking forward to it. I like working with kiddos and I am drawn to oncology. Plus it seemed like it could be a good fit for me. I also wanted to do a rotation at this specific hospital. That is one of the wonderful things about our one month clerkships, we get to try out different specialties, facilities, and organizations as we figure where we want to work and even what specialty we want to work in if we aren't yet sure.

Well, I am a firm believer that things happen for a reason and we end up where we are supposed to be. I was in my underserved rotation at the teen health clinic when I found out about the cancellation. I talked to my preceptor there and even though it took her a month or so to convince the organization, they took me on at a community clinic doing family medicine. It was a wonderful experience. And much more hands on experience than I would have received in pediatric oncology.

Surprisingly, they even asked me to come back for my preceptorship! And I'm happily returning after I finish my 6th and final clerkship, surgery (which I actually finish this week).

I would still totally love spending some time in pediatric oncology but sometimes you just have to roll with the punches!

Stay Encouraged!

Clerkship 4: Inpatient Medicine + My Top 10

So I will start off by saying inpatient medicine was a rotation I was looking forward to because it was on the hematology/oncology service and was very interested in working in heme/onc or primary care.

Or, I WAS... I am even less sure than I ever was about what I want to go into.

I still find rheumatology and heme/onc interesting, but now I also like infectious disease, psychiatry, dermatology, women's health, and just about every other field I encounter!

Here is what I know for sure:

1. People matter most, in this case, your work team and workplace culture! #1 PRIORITY FOR ME
   -PA friendly too
2. I like using my hands. (Love procedures-OR rotation is in March, so stay tuned!)
3. Seeing kiddos brightens my day. Peds specialty could be really cool.
4. A good schedule is important. My hubby prefers I don't have shift work right now. But, I would go for it later in life.
5. Commute to work. Location! Location! Location!
6. Scope of practice and the relationship with my SP are also super important.
7. Benefits are part of the package (CMEs, licensing fees, retirement, ect). Some loan repayment would be awesome!
8. I need to feel good about the rate of pay.
9. An environment that fosters learning is important. An on-boarding program is ideal.
10. I don't strive to be "the only one" who can do anything. Been there, done that.

So, what are your interests? If you are training or working as a healthcare provider, how did you narrow it down? I look forward to hearing your feedback!

As for my inpatient rotation, I worked at a local hospital on the inpatient service with heme/onc patients. The patients were wonderful, and also quite complex and so I learned a lot just being there.
I generally worked 3 shifts per week for 12 hours, 0745a-8p. The commute was half an hour or so for me and I spent too much money paying for tolls and for parking!

At the end of the day, as students, we pay our dues. I started my clerkships knowing every rotation wouldn't be stellar, but to always give it my best. PA students are a different breed altogether! Even in less than ideal circumstances we can find a way to make the best of it, take from it what we can, and to make an impact! And besides, any discomfort we may feel as a student in our rotations is temporary! We will move on!

I was on campus this past week. We listened to advice for life after this program ends, presented cases, and we took our 2nd ePackrat. It was nice to see my classmates and hear about their varied experiences!

Staying encouraged! The countdown continues!!!

*Disclaimer: I do not advocate the abuse of students or any member of the healthcare team. If anyone is in a situation that should be reported and addressed, I absolutely support doing so, starting with a trusted faculty advisor.

Clerkship 3: Emergency Medicine

I've definitely had a lot of experience working in the Emergency Department over my career. When I worked as a x-ray tech I took radiographs on injured extremities, ribs, and nasal bones, to name a few, achy tummies, and took countless cxrs too! As a nuclear medicine technologist, I mostly worked on call, performing exams to evaluate for pulmonary embolus, cholecystitis, GI bleeding, and brain death. I truly hated being called in for exams that pretty much felt like CYB (cover your butt) exams at all hours of the day and night, and all weekend too. And holidays. Hospitals are a 24/7/365 business!

However, this was my first time in the ED as a provider, and even in the student capacity, this caused me a little anxiety. Additionally, I don't feel prepared going into rotations (although I often find I am more prepared than I realized), but especially for the ED, where you need to think fast and know your stuff! I had not studied EKGs the way I wanted to and the suture kit I purchased for practice had not been touched. But, I talked with a student who completed the rotation, and loved it, which helped me feel a little better!

On my rotation I worked 11 hour shifts, including weekends. I am told this was to make sure students understood the nature of shift work in the ED, which I understood completely to begin with. But, I get it. And they didn't require me to work Thanksgiving, which was nice. Because 2 new grad PAs were just starting, besides my first day starting at 7am, I worked 11a-10p, and the training PAs worked the day shift. There was also an optional (for me) 5p-3a shift that the PAs rotated through. My commute each day was 45 min to 1 hour each way.

So, I really enjoyed this rotation! The PAs mostly work in a rapid medical evaluation area on this rotation. We do see critical patients, but these patients are quickly transferred to the main ED.
On day one, the first patient was a female with a double reproductive system who presented with abdominal pain. I went in to her room first and got the HPI, PMH, etc, and performed a PE, excluding the pelvic exam. Then I presented to my preceptor, including discussing the diagnostics to order, and differential diagnoses. Then I went in to the patient's room with my preceptor and he repeated some of the PE and performed the pelvic exam.
This was the routine for much of my time there. I worked most closely with 5 different preceptors, who all had a slightly different style. Generally, I assessed the patient first, and then the preceptor went back in with me to introduce him/herself and repeat some of the exam (or not) and we discussed diagnostics and differentials.

Day 2 I performed a digital block and sutured a laceration. I got really good at laceration repairs (if I may say so myself) and repaired lacerated fingers, hands, faces and scalps, etc. I'm most proud of a laceration repair I performed my last week where the scenario was man vs. chainsaw. The wound had jagged edges with visible fascia, so I repaired it using both internal dissolving and external sutures. Hopefully this will help me on my surgical rotation in a few months.

Due to my experience doing pelvic exams at my prior rotation at the Teen Health Clinic, and often being the only female provider around, I did many pelvic exams and procedures as well. I learned how to do a few other procedures also, such as how to fluorescein stain and exam the eye and I was able to get in plenty of practice doing I&Ds on abscesses, which is a good skill to have. 
I also learned so much more about antibiotics and other medications, and practiced with reading EKGs daily. Mental health conditions were also commonly addressed at this facility.

In conclusion, I did not get to intubate anyone or do chest compressions, (although I would go to code calls when I could) but I learned something in every patient interaction and have many new skills.

Next stop, inpatient medicine on a heme/onc service.

Welcome to the ED! 

Handy little device

Pretty snow, but ice too = sprains, strains, and fractures in the ED!

Clerkship 2: Underserved

In my program, we all have to do an underserved rotation. Mine was at a School Based Health Clinic, a Teen Health Clinic primarily.  I spent some time at a clinic at an elementary school as well.

School based health care practitioners manage medical conditions such as asthma and diabetes, and behavioral health experts address issues such as depression, anxiety, attention disorders, and social conflict. SBHCs provide immunizations, sports physicals and well-child visits, and health screenings. Many sites are offering services to support students in health education, social services, oral health, vision care, and nutrition counseling.

Eight out of ten SBHCs serve students in sixth through twelfth grades. The goal is to empower this age group to make healthy and positive decisions regarding their health. SBHCs have long focused on the health of adolescents and this effort has been proven to prevent school dropout by addressing barriers to learning. Some of those barriers include: drug use, teen pregnancy, violence, hunger, and poverty. These issues ultimately affect health, and the rate of high school drop out affects the nation economically and morally. SBHCs take advantage of their captive audience to make a major investment in their health, enabling kids to thrive.

Access to birth control has been a controversial issue for the SBHCs. However, only 37% of SBHCs provide birth control, and only 11% offer long acting reversible contraception (LARCs). Teen pregnancy rates are at historic lows, in part because teens are using contraception more, not because they are having less sex. In 2014 the American Academy of Pediatrics recommended LARCs for prevention of teen pregnancy, however, these methods are more invasive and longer lasting when compared with taking the pill. Therefore, it is difficult for many parents and guardians to get on board with their teen having access to LARCs.

I have truly enjoyed my experience at the Teen Health Clinic. I’ve never heard of such a thing until this clinical rotation, and I have to say it’s amazing. I saw patients who were technically homeless, living in shelters, transitional homes, and even in cars. In fact, during the 2015-2016 school year 3800 homeless students were identified in the district. The team I have worked with most extensively is the most caring group of individuals, from the office coordinator, to the health educator and mental health counselor, to the school nurse and the PA/NP medical providers. Everyone is invested in making a difference in the lives of the kids that come across their paths.

Fun thing about working at a school on Halloween: You get to dress up!

Everyone is welcome here.

Clerkship 1: Behavioral Medicine (Psychiatry)

At my program we have several one month clerkships and also a 4 month preceptorship in primary care. The preceptorship is either at the beginning or end of the clinical phase. Mine is at the end, so I'm doing the clerkships first.

My first clerkship was in psychiatry, and the setting was a public hospital. I was on one of the inpatient teams. Our team was led by an attending. We also had a PA, and half of the time we had a resident. There were two students on my team, a 3rd year Med student and myself!
We saw psychosis, mood disorders, eating disorders, along with complications from TBI and/or substance use.  I learned about medications and also about CBT, DBT, and other therapies.

I really enjoyed this rotation. I was able to start interviewing patients on the 2nd day of my rotation. I wrote progress notes, interim summaries, and discharge summaries on my patients. The Med student and I chose a couple of patients each for those tasks, and we split up tasks for other patients, like obtaining collateral or getting referrals, etc.

I had an opportunity to visit one of the state mental hospitals. The most eye-opening part for me was visiting the area that housed only children. The forensic area was also interesting. I also witnessed patients receiving ECT treatment. It's very benign these days, nothing like One Flew Over the Cuckoo's Nest, if you even know what that is. It's not barbaric at all. It's a very good treatment for certain conditions, including major depression, and very safe for pregnant women!

I went to lunch conferences twice weekly and to didactics also once or twice a week, which were always informative and helpful. I learned so much in this rotation.
I would like working in psychiatry, but I know for sure that in most every discipline, a knowledge of psychiatry will be essential to treating our patients to the best of our abilities! And also knowing when to refer!

A helpful book for your psych rotation: First Aid Psychiatry clerkship. https://www.amazon.com/First-Aid-Psychiatry-Clerkship-Fourth/dp/0071841741/ref=sr_1_1?ie=UTF8&qid=1476657629&sr=8-1&keywords=first+aid+psychiatry+4th+edition

During my psych rotation

For a reason, and for a season...

Summer session is quickly coming to a close and we are getting ready for new beginnings, life in the clinic!
While this portion of our training is often the most anticipated, I am feeling less than prepared. 

 
It is in times like these that I must remember that I really know more than I think I do. We crammed a lot into our brains over the last 15 months or so, not to mention all of the experience we acquired in the years leading up to this journey.

As I reflect on my time in PA school thus far, I feel stretched, supported, and a kinship with my classmates because they are the only ones who can truly understand what this ride has been like.

I am also a part of a prayer group which has been a Godsend, truly an answered prayer. This spiritual support has truly made all of the difference for me. 




I wish I had more time to blog about my experiences in didactic year, but I hope to at least make one entry per clinical rotation.

First up in a just over a week... Psychiatry!

Some of us during an optional POC ultrasound course this summer.