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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.


The “Crease”….Your Gyn Rotation

30 Sep

Some Things You Learn to Get Used To

If you’ve made through the didactic year and started rotations, chances are this may be a dreaded clinical. Prior to starting clinicals, my program hired people to allow us to practice the GU exam. I have no idea what low spot these people were in to allow 42 pelvic exams in a row, but maybe they were just dedicated to higher education. Luckily, I had some idea of what I was doing on my Gyn rotation….spending a lot of time in “the crease” before I set foot in the door. My most memorable patient was an elderly demented woman brought in from a nursing home. The chief complaint was “She put something in down there”. I was sent into the room with a non-verbal patient to do a pelvic exam. One of the CNA from the home was there to “help”. The speculum was lubed and inserted and….Whaaaaaat? There was not just one thing, there were THINGS. Plural people. I removed bottle caps, tea bags, and an eraser. What kind of nursing home was this? The emitted smell sent me to another world and I felt horrible for this frail old woman. I discarded the objects into the garbage and finished up the exam. After completing this almost impossible task, I got chewed out for not double gloving the previously inserted objects prior to throwing them away. I banked that one for future use! The following are a few heads up that no one ever told me.

1) Many gynecologists are not practicing obstetricians. If you want any experience with pregnancy or deliveries, make sure you find the right clinic.
2) Get your game face on, you will be seeing and hearing about some of the most intimate issues women face. Do not show any signs of surprise or you just lost your patient. As far as they know, you have always known that people get irritation around their recent clitoris piercing.
3) Prior to starting rotation, go over birth control methods. A large portion of the rotation will be about starting/adjusting/discontinuing contraceptives.
4) Dysfunctional Uterine Bleeding….own it.
5) If there are any procedures done at the clinic, get involved! Colposcopies, IUD insertion, Bartholin’s abscess I&D, marsupialization, among others are all really cool things to see, and will cross over to primary care and the ED
6) There will be pro-life/pro-choice discussions…its uncomfortable.
7) Women come to the clinic with very scary situations and diagnosis. Cancer diagnosis and abuse are two examples that pop into my mind. Guide and care for these women carefully.
8) Don’t judge. Its not our place. Gentle discussions about lifestyles are within our scope. Making them feel horrible about themselves because they are in being treated with a second STI from the same partner is not our place.
9) Please…..please, from the bottom of my heart, use lube on that speculum, every time.
10) This may be the job for you if you enjoy seeing many patients a day with similar complaints, but you get to know them at deeper level. There is some variation and higher complexity, but you have to be dedicated to pelvic exams. Many PAs enjoy a high level of autonomy in this field!

FOOTNOTE- I was corrected by a veteran PA who is in the Gyn field. She states that too much lube can actually ruin the wet prep or cytology results. Use in moderation

Slice ‘Em and Dice ‘Em: Your Surgery Rotation

2 Sep


My surgery rotation was at a busy hospital in Philadelphia.  I chose to do a more general surgery rotation to get a wider scope of what happens in the OR.  This included general surgery, colorectal, breast, and ortho.  My favorite was colorectal…not.  I never knew how they had to position a patient for rectal surgery, and let me tell you, it ain’t pretty.  Backside up, retractor in.  If you have never had a surgical experience,  be prepared for the brutality of it.  The patient is anesthetized, the music blasts, and there is no finesse necessary for getting the job done.  Mostly as a student you will be holding instruments.  You will be retracting.  You will be on your feet for 10 hours a day.  I was lucky enough to work under the chief resident who happened to look like Meg Ryan from City of Angels and she actually was pretty decent. Here are some heads up about what to expect.

1) Surgical residents get treated like pond scum….so thats the only way they know how to treat you.

2) There is a TON of pimping going on.  The attendings pimp the resident and the residents pimp you.  You should learn this phrase “I’m not sure but I will look it up and give you the answer later today.”

3) It would be helpful to get a pocket guide for the most common surgical procedures and their indications.  You will be asked about epidemiology, pathophysiology, anatomy, treatment, etc.

4)  Surgery Departments are typically boys’ clubs.  Unless things have drastically changed since I graduated, expect that it will be more difficult to be successful during this rotation if you are a woman.  There is a lot of male camaraderie and strutting going on.  “Oh hello, did you know I’m a surgeon?  Just wanted to remind the whole hospital how awesome I am” Just ignore it.  Show them your book smarts and be prepared.

5)  Go over sterile procedure.  You will scrub in so know how to it before you get there.  Know about the sterile field.  If you break the field you will be the most hated person in the OR for your entire rotation.

6) The surgical techs are gods in the OR.  They know every instrument, how to handle them and how to maintain the sterile field.  They may help you get your gown and gloves on.

7)  Expect to stay late.  Everyday.  There will always be a late, add-on, once-in-a-lifetime case that you would be a complete idiot to miss.

8) Continuing off of #7, sometimes you can’t stay late.  Its okay to say no if you have something REALLY important happening.  An example would be that you are in labor and your water breaking would contaminate the field.  If you truly have to leave on time, just be prepared to get some seriously disappointed looks.  If you can handle it, walk out the door with your head up.

9)  Bring protein bars…at least 3 or 4.  Lunch break is rare.  Breakfast and dinner breaks are even rarer.  Pretty soon, that mass you just helped remove will start to look delicious.  Gross.

10)  This may be the specialty for you if you find out that you like instant gratification.  Someone’s gall bladder turns black, you take it out.   BOOM!  The End. There is less direct patient contact, but you are in close contact with your supervising MD everyday.  In all seriousness, surgeons typically come from the top of their class.  There are many kind hearted and gifted surgeons that you can learn a great deal from.  So be prepared to work long, hard hours this rotation.  Suddenly the textbooks will be replaced by real people and so many pieces of the puzzle will fall into place for you.  I promise, retracting is not nearly as bad as it sounds 🙂

First Rotation

28 Aug

Here is a picture of the end point.  Or I guess the beginning.  Long before you get a Master of Science in Physician Assistant Studies you have to enter into a grueling didactic year and than an even more grueling rotation year.  Let me back up a little and let you know how I got to Philadelphia University.  It all started when I was rejected by my home town program in Minneapolis, MN.  Augsburg College.  The Mecca of PA programs in the midwest.  I obviously had a safety school….which I did not get accepted into.  So I submitted my very expensive application to Philly U, PU for short.  I flew out for an interview and tah dah! moved to Philly months later.

I have lived internationally multiple times in my late teens and twenties, but nothing prepared me for the culture shock of the East Coast.  I moved into a house with four strangers and off we went.  First of all the house was in Manayunk, what kinda name is that?  Hot, steamy, cement everywhere.  Ah, the memories are many from that first year.  I will get back to the didactic year but today I am going back to my first rotation…

So there I was.  My short, snow white, pa student coat.  My frumpy “professional” clothing.  My “I’m gonna change the entire healthcare system” attitude.  I walked into an inner city primary care office and tentatively knocked on the open door of my attending’s office.

“Who the fuck are you?” was the first question out of his mouth.  I stood there and awkwardly tried to explain that this was the first day of my first rotation.  That was a long twelve weeks.  This doctor I worked with called himself white chocolate.  He was a Caucasian who did work with a primarily african-american patient population.  And it was true that his patients adored him.  But the number of off color, rude, and demeaning comments that came out of his mouth was astounding.  Although going to that office every day was painful, I learned a lot about how to adjust your practice style to reach different cohorts.  I also learned to let some things roll off my back.  There were lots of moments where I felt belittled, but I kept going and I was able to learn a different kind of compassion.  Maybe my conservative, reserved, swedish style would not work with many, no most, of the patients we PAs are in the business to reach.    So hang in there during those tough moments.  Take a second to look at the world from a different point of view.  Try not to shut down when you don’t understand the whole situation.

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