Archive | October, 2014

How to Say No to a Drug Seeker

30 Oct

smoker blog

The reason why I chose the above photo is because many of us are addicted to substances.  Coffee, cigarettes, alcohol,  drugs, all can lead to unhealthy consequences.  That’s me up there smoking.  Just kidding.   I’d like to think that I looked that good when I smoked.   After recently quitting, I can tell you first hand that habits suck.  I always try to have compassion with my patients, but often fail miserably with drug seekers. When someone comes to the ER with the goal of getting narcotic pain medications to feed the “beast”, I have to take a breath and try to remember that they probably aren’t real happy with themselves either.

There are many legitimate reasons  for drug seeking at an ER.

1) Kidney Stones

2) Bear Mauling

3) Severing/Breaking of Limbs

4) Abscess (especially if in a “sensitive” area)

5) Rupture of Any Internal Organ

This is not an exhaustive list.  These patients have an underlying medical or surgical condition that require emergency intervention that will likely include pain control.  The people that come in for chronic issues, or for a fix,  push to the waiting room those who may have more serious illnesses.  (The little old lady with a red leg for 2 weeks is less of a priority than the 45 year old writhing and retching with three months of abdominal pain.) The person who comes in with abdominal pain for the sixth time that week may have developed a true surgical pathology, like an appendicitis, so the key is to push aside your bias and look at the patient with fresh eyes each time.  After you have ruled out any medical or surgical emergency, its time to give the patient the bad news.  The following is a  mock conversation to give you a few ideas about how to respond to the patient.

Practitioner: We found nothing in your work up today that requires narcotic pain medication.

Patient: But  I am IN PAIN!  Isn’t it your job to help people?!?”

Practitioner: I feel that the best way to help you is to encourage you to get to your (primary care, gastroenterologist,  neurologist).

Patient: The last doctor gave me Percocet!

Practitioner: I’m looking at your symptoms and concerns for today’s visit, and I don’t feel that narcotic pain  medication is going to be helpful in the long run.  Here is a list of things you can do at home to help with your symptoms.

This may be where things get really ugly.  My suggestion is that you remember that it is not the patient talking, but the beast that is their addiction.

Patient:  You are a #$%^@!  You don’t even understand what this feels like!  Have you ever been in pain?!?

Practitioner: I am sorry that you are in pain, but we are not sending you with narcotic pain medications.  If you are having chronic pain then you need to see a specialist for that.  I am going to get your paperwork for your discharge.

Mic Drop!  

Do not let this portion of the conversation go on and on.  You might cave and fuel the beast, which is actually hurting the patient.  Here’s the kicker.  Many times I have literally been walking out of a patient room when they throw out a new complaint.  I had a patient that came out of her room, followed me to my work station, and then complained of new chest pain.  I explained that if she is having new pain that we need to discuss that in her room.  The patient then stormed out and said that I wasn’t going to evaluate her chest pain and that I was going to be in “big trouble”.  I covered my bases, documented well, and let it go.  That’s all I could do.

To summarize, always treat a patient with respect, rule out any true pathology, stick to your guns.  There is a designer drug addiction epidemic in the US and as ER clinicians we are the first line of defense.  Use your best judgement, but sometimes you will have unsatisfied “customers” and that may be an indicator that you are doing a good job.

Have you ever had a difficult patient?  How did you respond?  Please comment below!

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My Mama’s a Physician Assistant

26 Oct

working mom chaos

I always thought that I would be a mother some day. And I always thought that as a liberated woman I could have a full time career and manage my family with ease. I finish that sentence with a loud, resounding, “Ha!”. It all started to unravel the night before I went back to work for the first time.

I was only able to take five weeks maternity leave. Do you know how ridiculous that is? My rectus muscles were still completely ripped apart but my job at the time wouldn’t pay for a decent leave. So me and my broke self got up on a Monday to return to work at a small clinic, breast pump in hand.

The night before, I crawled under my covers and sobbed. I was a bad mother! How could I leave that precious babe in the hands of an incapable person for a 12 hour shift? They would never be able to hold her, feed her, sing to her like I do. My  baby girl was going to grow up with attachment issues. It took me a few weeks but I eventually decided that my mother was, in fact, capable of caring for her granddaughter. Three kids later and I have learned a few things that I wish to share with you, working mama,

1) It really, really sucks when you forget your breast pump. Pack everything the night before and have it by the door.

2) Take as long a maternity leave as you possibly can.  You just can’t get that time back.

3)I realized after having three children that it doesn’t get easier being  a working mom….you just get used to the chaos.

4) Cereal for dinner is perfectly acceptable in a pinch.

5) Your kids will use words like “trachea” and “pupil” and “femur” and its kind of creepy.

6) Sometimes you just have to cut back on the number of commitments you make.  Just be sure to hang with your friends and that your social life doesn’t completely fall to the wayside.  Balance, people!

7) At first I felt like I was never good enough, either at work or at home. I’m still working through that one! Sometimes life is just hard and you do your best, and that has to be enough.

8)  Going off of # 7, ASK…..FOR…..HELP

9)  Let your kids help with life at home.  Don’t do things for them because you feel guilty.  I fell into that one and will write more about it later…

10)  Let go of perfectionism.  Your kids love you and they only have one childhood.  Worry less about how you want to be perceived and more about getting in extra snuggles.  What tips do you have for working moms in the medical field?  Comment below!

Ankle Biters- Your Peds Rotation

24 Oct

This man has learned the art of administering vaccinations and truly a master with kids. My pediatric rotation was a nice change of pace from some of the hospital based clinicals. It helps that I like children. I will tell you about my most mortifying moment during my rotation.

Much of my day was spent doing routine physicals. I walked into the exam room and met my patient and his mother. After completing the majority of the exam I asked if the mother wanted to step out so I could preform the genitourinary exam. Did I mention this was a 15 year old boy? Did I mention that I was a 24 year old woman? I started the exam and tried soooo hard to be professional even though it was awkward and weird. The patient lifted his gown and had an erection.

“Turn your head and cough!” I’m not sure if I truly evaluated for a hernia or not but I was out of there in a hurry. Why did no one tell me what to do in this situation? I can tell you it was not the last time its happened. Maybe I should have said “It happens, no big deal.” Let me know if anyone has a good script for that situation. Here are a few other things that I learned on that rotation.

1) You will be doing a lot of vaccinations. Get comfortable with the vaccination schedule an catch up schedule.

2) In the current age of Jenny Mccarthyism, parents have a lot of questions about the safety of said vaccinations. Know the side affects, ingredients and the CDC statistics of illnesses that you are vaccinating against.

3) This is a great time to hone in on your physical exam skills. The sucking reflex and moro reflex are kind of hilarious. And the healthy newborns do it every…single..time.

4) Kids are not little adults. They have different diseases, different neurological pathways, and are different developmentally.

5) Expect to see a lot of rashes. Oh my gosh, so many rashes! Study up on how to describe those vague, irritating, skin changes.

6) Learn to respectfully say, “Your child has a cold”

7) If there are rare endocrine patients or genetic disorders make sure you get to see these patients. You may never see these diseases again.

8) Talk directly to the child, especially adolescents. They appreciate directness and being treated like a human.

9) Kids are sexually active at a very, very young age. Sad, but it is the reality. Ask the parent if they are comfortable stepping out so that you can talk about their sexual history. Some parents will refuse and thats ok too, but you need to bring it up.

10) This may be the specialty for you if you like to see a patient over a long time span with lots of developmental changes. There is a special bond with kids and their pediatrician. There are also heartbreaking diagnosis that sting a lot more when you are dealing with a young person. It takes a special person to be with kids all day, but it rewarding in a different way than adult medicine. Parents are trusting you with their most precious possession, and that is a relationship that deserves the utmost respect.

The Ethics of Ebola

18 Oct

file0001786007208 rae scrubs surgeon green white mask glasses

Is anyone else a tinsy bit nervous about the Ebola crisis? The blame game has started, exposed people have been on airplanes and cruise ships. It is likely that Ebola may come very, very close to home. We are getting mixed messages about transmission from the media and the CDC. This is not about any more scary statistics. We are scared enough.

My question to you comes after a discussion I had in the Emergency Room tonight. I was working a shift and the nurses were discussing the lack of education they have on personal protective equipment, or PPE. We began talking about disaster preparedness and what our little ER in inner city minneapolis is prepared to do.

Here is the kicker. I was asked if I was willing to be a part of an ebola response team should it reach our community. A specialized task force to help treat and contain an Ebola crisis if it came to Minneapolis. The answer for me was yes, but I am conflicted.

As healthcare providers we sign up to help people in all circumstances. Sometime at the risk to our own health and well being. Particularly in the ER when we come across volatile patients, antibiotic resistant infections, blood-born illnesses, we have heightened risk compared to many other forms of medicine. We know what we are getting into as PAs. No one said this job was risk-free.

So why is it that Ebola is any different? There are nurses, docs, advanced practice providers and other medical personal that theoretically could opt op of caring for Ebola patients. What are the repercussions of this? What about the hippocratic oath? “I will apply, for the benefit of the sick, all measures which are required”.

There are people dying in Africa because they don’t have access to basic healthcare facilities. There is a healthcare crisis as Ebola spreads, and people with treatable illnesses fall to the wayside. We have the privilege living here to have the equipment and knowledge to contain this disease. Is it our duty to help, or can we “opt out”? Is it selfish to avoid being involved? What do you think? Write your comments below.

Wounds and Generators: My Health Care Experience

14 Oct
IMG_1059

Talking to a cholera patient in Limbe, Haiti

Becoming a Physician Assistant is not a light decision. It makes sense that programs would expect you to have experience in healthcare prior applying for school. Seeing as this is a decision that may guide you to happiness or your own destruction, you should check it out first! No pressure.

I never knew about the PA profession until my sister married one. For six months after college I did some serious soul searching. Med school? PA school? Did I mention that those six months were spent in Haiti? The time I spent there was indescribable. The improvisation and just barely getting by every second never ceased to amaze me. The Haitian doctor I worked with allowed me to suture, administer vaccinations, start IVs, preform pelvic exams and help with the start up of a clinic in rural Haiti. This is the hands on experience that PA programs are looking for.

We had a patient that came to the clinic for a severe asthma attack. She was wheezing, tachypneic, using accessory muscles, and lots of other stuff that made her look really sick. The electricity went out (again) so we hooked the nebulizer up to a generator. She was sitting there with a neb as the exhaust from the generator spewed into her face. Seemed counterproductive but we had no better options.

There was another patient who had an accident 12 years before and had a penetrating wound to the lower back. Because he was a diabetic he had very poor circulation and wound healing. I pulled out a snakelike bandage from his wound and changed it daily. 12 years and it still was not healed.

These are the kind of experiences that made me stand out during my interview (yes, one). But if I was not genuine they could have smelled it before I came through the door. You have to love patients. You have to love medicine. You need the experience that proves this, more than just being an occasional volunteer at your local hospital. What kind of experiences helped you to decide to get into the PA profession?

HAPPY PA WEEK!

10 Oct

I have no idea how they found time to do it, but these students made me giggle. They are obviously excited about the PA profession, and why not? Here are my top reasons for loving what I do, and why physician assistants rank in the Top 25 careers for 2014.

1. I get to be a detective everyday to find out what is wrong with people.

2. There are an endless amount of options for what type of practice setting I get involved with.

3. Mad cash, people. OK, so not like the top 1% but I feel that I can provide for my family and get to go on a few vacations too!

4. I heart my coworkers! I work with great nurses, techs, phlebotomists, pharmacists, NPs, MDs. There is mutual respect and we work as a team.

5. When I am done for the day, I go home and don’t think about reimbursement, RVUs, if the hospital is in the red…I’m not running a business, I’m taking care of people.

6. The PA profession is getting noticed and I spend less time explaining what I am to patients.

7. We are part of the answer to a growing healthcare crisis. Affordable, high-quality care.

8. PA schools pick out the cream of the crop, so we end up with a very talented group of people. Very few people just “fall” into this career. We end up with a bunch of passionate providers.

9. There are always new things to learn. New procedures, medications, diagnostic tools. I am always growing.

10. The final reason I love being a PA is that it is a stable career. I do not have any concern that tomorrow there won’t be a job for me. Why did you choose the PA career path? Comment below!

Blood, Guts, and Bones…Your ER Rotation

6 Oct

Medical research and studies

I must say that I have been working in the ER for 6 years now so I am a leeeeetle partial to this rotation.  My rotation was in a busy, level 1 trauma center.  It was an intense, mind blowing 6 weeks.   Stress levels run high and there is always a lot of action.  There is also a disproportionately large amount of bull crap complaints, which you will notice right away.

I had an interesting emotional response during my ER rotation.  We saw a few trauma patients with gun shot wounds.  These were young men who died of senseless violence.  One free Friday night my husband and I went to see the movie “Departed”.  I know, one of the best crime movies with some seriously gorgeous men.  Although I did enjoy Leonardo Dicaprio and Matt Damon, I walked out of that movie in a near panic attack.  The shoot em’ up scenes hit me in a new way.  I watched people die, in real life.  The violence and death I experienced in the ER shook me deeper than I knew.  The ER is a place where you see people at their most vulnerable and scary moments.  We are a key player in these moments and that can take a toll on you emotionally.

The following are some tips to get you through your rotation.

1.  Be on time…in fact, be early.  Shift changes are key times of sign out and you will be better prepared if you know what is going on with the current patients.  You will also likely learn something about diseases and treatments.

2.  Make your presentations succinct.  There is nothing more irritating then a long, drawn out, fumbling patient presentation.

3.  Know your differentials.  The ER is a little different than your primary care rotation in that the attending will want to know mainly the life or limb threatening possibilities.  Always have five possible diagnosis and say them with confidence!

4.  If you can be a part of an end-of-life discussion you should be there.  This is more of the “art of medicine” that we all need more practice on.

5.  Patient education takes a lot of time.  A LOT of time.  I had a patient who was scared because she thought she had “poop coming out of the wrong hole”.  It was not.  My cartoonish drawing helped clear that one up.

6.  ATLS, PALS, ACLS are all important to know.  When you are part of a code, try to think preemptively what meds and procedures should be done.  You will understand the process better if you try to think for yourself.

7.  In my ER, PAs do central lines, chest tubes, intubations, sutures, I and Ds, dental blocks, joint reductions, splint applications, among other procedures.  You will not get a hang of these in 6 weeks but its important to know the indications, instruments, and meds used.

8.  Nurses, Techs, Medics,  HUCs…They all make the ER roll along and most of them know more than you do.  Show respect.

9.  Be assertive.  There will likely be Med students, NP students, nursing students, medics in training all trying to get in on that code or procedure.  If you don’t get yourself involved no one is going to coddle you along.

10.  The ER may be the career choice for you if you enjoy fast paced, high adrenaline settings… and you don’t mind having a schedule that is opposite of all your friends’ and family’s.   PAs get to use a large skill set and it is cool to help save lives in real time.  You also see some really heart wrenching things and you have to be the type of person who can leave work at work.  Did I say that I love the ER?  Comment below if you have questions or great stories.

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