Coming Full Circle

Early August, 2011, I landed a back office medical assistant job at a podiatry office in Concord, CA. I had just graduated from college two months prior, so I felt fortunate to find meaningful employment so readily. It wasn’t until two years later when I was accepted to PA school that I realized just how lucky I was to find this job. While working at this clinic, I assisted with many out-patient procedures, one of which being ingrown toenail removal. I recall many, many of these procedures, and I also remember thinking to myself that I was fully capable of performing the same feat, given the opportunity. Unfortunately and understandably, I was not “qualified” to perform said procedure; thus, I remained relegated to the prepping and clean up role.

Last week, around 5:15 AM, while working another emergency department (ED) night shift, I removed a young woman’s ingrown toenail. I was scheduled to finish the shift at 5 AM, but opted to stay longer to complete the procedure. I know what you’re thinking. You stayed late to remove an ingrown toenail? Yes. I did. And I smiled the whole time. It was incredibly satisfying to realize that I had come full circle with the summer of 2011, and was now qualified to complete this task I had seen performed at least 100 times.

Will I be that eager to remove more ingrown toenails? Probably not… but this first one was definitely a personal milestone marker, as odd as that sounds. In fact, I text messaged my old boss the next day to tell him. He got a kick out of it.

As my ED rotation came to a close, I really started to get a feel for my role and my capabilities in the hospital. In the last two weeks, I packed a bloody nose with a Rhino Rocket, performed a couple smelly vaginal exams on itchy women with discharge, and administered my first dental nerve block on a guy with an unrelenting toothache. Regarding that last bit, I must say it’s far more pleasing to be the person injecting the gums as compared to the guy receiving the injection. Although, I will say he was very happy with the freedom from pain I afforded him.

All in all, the ED is a fast-paced environment that (depending on where you work) affords PAs a great deal of responsibility, and I truly enjoyed that — so much so that I am seriously considering using one of my electives to do another ED rotation with the Valley Health System with hopes of being hired once I graduate.

With my other elective, I might find myself practicing medicine in a faraway, third-world nation I never thought I’d see — Tanzania. In case your geography is as poor as mine, Tanzania is located along the East coast of Central Africa.

Woop, there it is.

My school offers two out-of-the-country rotations each year, and students have traveled to Guatemala, Tanzania, and Thailand since the school’s inception in 2004. Anyway, an email circulated calling on those that might be interested in traveling to Tanzania in July, and I (along with five others) replied. We should find out this week who has been selected to go as there is only room for four students, but I remain hopeful that I am chosen. Whomever ends up going, what an opportunity the trip will be to learn, explore, grow, and most importantly, serve.

Mt. Kilimanjaro

Although I completely, 100% believed that I failed my emergency medicine end-of-rotation (EOR) exam, I passed. Not only did I pass, but I scored my second best EOR grade. This is generally gratifying, but I’d really love to review the exam because there were a bunch of questions in which I thought, “Shit, it’s either A or C. Ahh, screw it,” and guessed. So now I’m left wondering what the hell the answers were.

In any event, it was great to see all my friends again, including the return of Judith!

PA Framily

My next rotation will be pediatrics (peds), and it begins tomorrow morning at 9 AM. I’ve heard good and bad things about peds, but it is the bad that stands out. A preceptor of mine (who shall remain nameless) once said he equates pediatrics to veterinary medicine — “He won’t eat, he’s shitting all over the house, and he won’t stop whining. Now, which am I referring to — my child, or my dog?” He makes a valid point; I’ll try and keep an open mind.

My mom, my sister, her fiance, and a bunch of friends flew out to Vegas last weekend for bachelor/bachelorette parties. On Saturday night we all went out to Hyde at the Bellagio and had a booth and bottle service. It was a lot of fun. I wish I could tell you more, but that’s all I can recall.

Angela, Me, Jami, Bryan

Until next time…

Me and my main girl watching season 3 of House of Cards

Emergency Medicine

Swiveling away from his computer screen to face me, the doctor says, “You see, Anthony, something you need to understand right out of the gate is that you students drag us down. As soon as we take a student, our efficiency is cut in half. In fact, we call you ‘tar babies.’ Do you know the story of Brer Rabbit?”

“Uhh, no?” I manage.

He continues, “Brer Rabbit was always pestering Brer Fox, so one day Brer Fox decided to make a cute little baby out of tar to try and trap Brer Rabbit. So he set this tar baby in the middle of the path and Brer Rabbit found it. When Brer Rabbit tried to talk to the baby, of course it didn’t respond (because it’s made of tar). Well, Brer Rabbit got upset for being ignored and tried to whack the baby which caused his right paw to get stuck in the tar. Trying to free his right paw, his left paw got stuck. Then he tried to kick his way free and his hind legs got stuck. The rabbit gets away in the end, but that’s not the point. The point is this: you are tar.”

Brer Rabbit and the Tar Baby

The above is what my emergency medicine precepting physician said to me when I showed up for my first day of rotations. Quite the warm welcome! I got the message loud and clear.

I followed this doctor around for most of my first day, but was soon pawned off to the physician assistants to see what they do. If there was a breaking-in period in my other rotations, there was going to be no such thing in emergency medicine. By the end of the second day I was thrown to the sea (patients) and it was sink or swim.

It’s been two weeks now. I’ve worked with four different PAs, and I’ve generally been very pleased with the amount of responsibility that they have afforded me. Most have been very helpful, kind, and understanding of my status as a student that has a lot to learn still. Nevertheless, my experience thus far has been enjoyable. Truly, I have a lot of cool stories to share, but I’ll just pick and choose a couple. As much as I’d like to share more, February is a short month which means my end-of-rotation exam is fast approaching, so I need to study.

On my second shift, a 15-year-old Latino male presented with severe scrotal pain for 1 hour that began suddenly while he was sleeping. The PA I was working with and I examined the boy and found that his right testicle was firm, red, and severely tender to palpation/manipulation. We suspected right testicular torsion, a condition in which a testicle becomes twisted on its stalk. We ordered an ultrasound (U/S) of the testicles to evaluate for blood flow because torsion can cause decreased blood flow to and from the testes.

Confirming our suspicion, the U/S noted decreased blood flow to the right testicle — a surgical emergency if not corrected as soon as possible. In fact, we’re taught in school that if the testicle is not untwisted within 12 hours, there is only a 50% chance of saving it. If accomplished within 6 hours, the patient has a 90% chance of recovery. With this in mind, and because torsions are (apparently) rare at this ED, we consulted with the supervising physician who promptly asked me if I wanted to try to fix it.

“Sure!” I replied.

Right away, the three of us walked over to the patient’s bedside and closed the curtain around us. With us in this confined space was the patient’s mother and older brother. The doctor addressed them, “Your son has a twisted testicle. We’re going to try to untwist it, but if we can’t do it here we will have to send him to a hospital with a pediatric urologist on call for immediate surgery, okay?” The three of them were pale with fear by the time the doctor finally said “… and my student, Anthony, is going to try and fix it.” Quite the introduction.

I asked the patient to stand and drop his pants. I got down on one knee before him, placed my left thumb, index finger, and middle finger on his right testicle, and rotated it counterclockwise. In about 20 seconds I was able to unwind it 3-4 revolutions before it wouldn’t spin anymore. I asked the kid how it felt and he said, “Umm… It doesn’t hurt anymore!” He said his pain went from a 10/10 to 2/10. Repeat U/S demonstrated blood circulation had returned to the testicle and the patient was discharged from the ED 30 minutes later.

A few days later during another night shift, I found myself sitting too close a deranged, delusional, angry, and violent man. It was a half-hour before my 10-hour shift was over, and my precepting PA told me we were going to make rounds in the psychiatric holding bay. This is a sectioned-off area of the ED where patients are held for psychiatric reasons for up to 72 hours. While these patients are being held, it’s our job to verify that they don’t develop any acute medical conditions by checking on them a couple times per day to evaluate their heart and lungs. It’s supposed to be a really quick thing. My preceptor didn’t tell me this, though, so I approached the patient the same way I had been approaching patients all night. I sat beside him and said, “Hi. My name’s Anthony. I’m a PA student that’s working here with the doctors. What brings you in tonight?”

He turned his scowling face toward mine. “What brings me in?!” he questioned. “You brought me here!”

I was like…

He continued, “You lied to me to get me out of my hotel! You lured me in and said there was $250 in a bag around the corner, so I follow you outside. Then you put me in your cop car and take me here! Oh, and don’t forget you called my sister who’s 3,000 miles away and wanna believe her stories about me. My sister is a liar and you know that! I can’t believe you got me holed up in here with these crazy people. That guy over there is coughing up his left lung and now you got me in here being held against my will. Don’t think for a second that I don’t know what’s going on here; this is antisemitism at it’s finest. I’ll have you know that I’ve already called my Rabbi and he’s meeting with our lawyers right now. You’re screwed, buddy. You’re screwed.”

Me while listening to him

“Okay, well can you lean forward and take a deep breath so I can listen to your lungs?” I asked.

“Sure! No problem!” he replied.

I have so many more stories that I’d like to tell but don’t have time for. For example, the guy that said his urethral discharge was normally an off-white color until I explained to him that urethral discharge was not “normal” only to realize he was referring to his ejaculate.

• I’ve been able to participate in a couple resuscitation efforts on people with a heart attack/lack of breathing.
• The first time I sutured in the ED was on the inside of a 16 year old boy’s bottom lip. He cut it with his teeth when he landed on his chin after jumping from his 2nd story balcony “just to see if [he] could.”
• I’ve drained a handful of abscesses. One was in a man’s mouth and when I punctured it, the contents of the abscess spread all over his tongue, causing him to vomit.
• I removed a nickel-sized blood clot from a quarter-sized thrombosed hemorrhoid.
• I’ve also been able to diagnose new onset congestive heart failure, atrial fibrillation, cholecystitis, acute pancreatitis, and nephrolithiasis.
• All in all, the emergency department has been an awesome learning environment. This is the most hands-on I’ve been since beginning clinical rotations, and I’m only halfway done.

Last year at this time I was in New Zealand. As such, I’ve been really nostalgic lately. I can’t wait to travel again. I don’t know where, when, or with whom, but I’m hoping that it comes sooner rather than later. Here’s some throwbacks for old times’ sake.

Lake Wakatipu, Queenstown, NZ

Somewhere in the forest, NZ

Look back at it

Queenstown, NZ

Milford Sound, NZ

Lastly, I’d like to dedicate this entry to Max. Max was (openly) my sister’s favorite cat and he passed away in his sleep earlier this week at the young age of 6-years-old. I didn’t know him as well as my sister did, obviously, but I’ll always remember the little guy as a Play-Doh-like creature that was so chill that he’d let you hold him and fold him and mold him into whatever you wanted. He was soft (and fat) enough to be any shape. He ate almost anything, but if he didn’t like something he would dig around it with his paws to let you know he thought it smelled like shit, literally.

 

He was an awesome cat and a better friend, and he will be missed by all that knew and loved him.

R.I.P. “Kitty Boy”

 

Unleashed

Friday, January 30, 2015 marked the end of my two month family medicine rotation and subsequent end of rotation exam. The first six weeks were sort of a mixed bag, as I was limited by my preceptor, Dr. B, to only seeing new patients by myself while he saw all of the existing patients (about 90% of the daily schedule). I was just a wallflower in the treatment room. Understandably, it was hard to stay focused when I wasn’t being forced to critically think. I took plenty of notes, but barely got any patient interaction, let alone physical exam skills practice. Dr. B told me several times how well I was doing, but he still wouldn’t let me treat his existing patients. When I asked (on two separate occasions) if I could see some patients, he said, “Oh yeah, we’ll get you in there real soon,” but never did. Fearing that he wasn’t confident in my abilities to see his patients, I asked one of his medical assistants if other students had it this bad. She assured me that Dr. B pretty much never lets students see existing patients; that’s just his M.O. With two weeks remaining in the rotation, I had accepted my fate and resolved to try my luck in my next rotation. However, as fate would have it, Dr. B developed a direct, incarcerated inguinal hernia that required relatively emergent surgery to correct it. Accordingly, in order to finish my rotation, I was passed on to the only other doctor that works at the office, Dr. S, a gynecologist.

To be fair, he may be a gynecologist, but Dr. S has ample experience in family medicine given that he frequently sees the family med patients at this office when Dr. B gets behind in the schedule. Anyway, on my first day working with Dr. S, he says to me, “I do things a little different from Dr. B. I’m gonna have you see the patients, and then we’ll discuss them if you have questions.”

“AWESOME!” I thought — exactly what clinical rotations are supposed to be! I was thrilled to finally be unleashed. During the first 3-4 days I was in total control. The patients presented their problems to me, and I responded by asking questions and evaluating them before deciding what needed to be done. This is a generalized way of saying that on a daily basis I was ordering and interpreting in-office X-Rays, prescribing antibiotics for infections, interpreting blood lab results, starting patients on new medications as needed, and even changing medications if their current regimen wasn’t working. If ever I was stuck or didn’t know what to do, I referred to my collaborating physician, Dr. S, just like I will do when I’m working as a certified physician assistant. Otherwise, I was calling my own shots, initialing my own patient visit notes, and checking off diagnosis and procedure codes on my own billing sheets.

In fact, I had taken on so much responsibility that on day four, the company biller approached me and Dr. S to ask us about our methods. He was concerned because he was seeing a number of billing sheets come through with only my name and initials on them. He asked, “Hey, are you (Dr. S) seeing these patient’s that Anthony is seeing?” “Some of them, yeah, why?” Dr. S replied. “Because we are billing under your name for all of these visits, so you need to see them too. We can’t bill under a student,” explained the biller. Dr. S and I shrugged and agreed that Dr. S would start “seeing” the patients after I did, as in, once I was finished with the patient, I would leave them in the room for Dr. S to open the door and say, “Hi, do you have any questions? Okay, have a nice day.” That’s how the remainder of the rotation went.

It was so much fun! I can’t even begin to explain my excitement. I was finally doing what I’ve been spending all these agonizing days, weeks, and months preparing for! At the end of each day I was swelling with happiness knowing that I was making decisions to improve someone’s well-being. It’s an intensely gratifying sensation to be presented with someone that is legitimately concerned for their health and you have the ability to help them and give them peace of mind. This is the very reason I decided to become a PA — to teach, lead, and serve.

In those two weeks, I encountered numerous medical conditions, and even diagnosed a number of new ones. For example, I saw a 20 year old male who complained of a lump on his testicles. After inspection, I informed him that it was just a varicocele. I also diagnosed more serious diseases like bladder neck cancer in a 52 year old male. I was surprised at how classically it presented — painless blood in the urine of a longtime smoker. I put my arm around a woman who’s six year old son threatens daily to kill her — recently stabbing her in the ribs with a pen — and I let her cry. I counseled a 54 year old retired high school principal to stop drinking a six-pack of beer/day with his buddies because his liver is failing. I explained to a 43 year old woman that her dry skin, hair loss, fatigue, cold-intolerance, constipation, and weight gain wasn’t because she was “getting old and gross,” but because her thyroid was hypoactive.

Countless times I heard the same things from patients — “Thank you for listening to me,” or, “Thank you for taking time with me,” or, “No one ever told me that before,” or “Thank you for explaining it to me.”

Now that I’ve tasted freedom, I want more. February will introduce me to the field of emergency medicine, and I will have to start from scratch all over again — earning responsibility day by day. I start on Tuesday (02/03/2015), and I’m feeling ready. I’ve heard that I will be doing a lot of suture work at this hospital, and I’m quite excited about it. In preparation, today I practiced suturing on the pig face I bought on Saturday. I named him Babe. Sadly, though I tried my best, I was unable to revive Babe. It probably had to do with the fact that I couldn’t locate the rest of his body. Nevertheless, I put in some good suture work on his face and gave him a fighting chance.

Before

After

Speaking of preparing, I came to realize recently that I study much more than I probably need to. I spoke with a number of my fellow classmates and the range of time dedicated to studying varies quite a bit, with some saying there are many days that they don’t study at all. I’m definitely on “study-o-holic” end of the spectrum. With the exception of 1-2 days per month, I study every single night after clinic, including taking and reviewing practice exams that range from 20-60 questions in length. Perhaps I don’t need to study so much, but I have resolved not to change my habits. I don’t study for tests; I do it to learn. I intend to be the best at what I do.

#Determined

Seven exams, including my board exam, stand in my way, and if I were them I’d be pissing my pants. I’m careening down a collision course with each of them and picking up momentum as I go.