Snow and the business of skiing

Today was crazy in the emergency room. I have been asking myself why and have come up with several reasons.  1. the ER is unpredictable, you never really know when you are going to have a rush of patients.  2. It is Sunday, most urgent care centers are closed.  3. There hasn't been much snow to accumulate on the mountains, many ski resorts are making snow because they were determined to open by this week, but the snow it is like ice instead of a nice thick bed of powder. Ice = injuries!  Today I saw three patients with vertebrae fractures, two of which had to be transferred to nearby trauma centers for emergent surgery. One patient should have been paralyzed after viewing his images but his motor and sensory neurological exams were still intact.  For many reasons I am hoping for some snow while I am here, one of them being I have some exposure to ortho cases other than spinal injuries.

Lake Tahoe

Distance

Home

Last week I experienced for the first time what it feels like to need to be home, to be with my family during an emergency, but have no easy way to fill that need. This need makes one feel alone. This need makes 2,000 miles seem like oceans away. This need makes one desperate. However, as a student I have learned to put my needs aside, and I was in the process of doing this when my clinical coordinator, stopped me in my tracks. She told me to stop preparing for my next move to Truckee (where my seventh rotation is), pack my bags and book a flight home. Which is exactly what I did with the help of many.  During times of crisis, when you are most vulnerable it is astounding the people who are supportive in so many unexpected ways.

Thank you Bruce for booking me a flight home with a few minutes notice and acting like its no big deal. Geoff and Kat for dog piling/bear hugging me while I finally processed all my emotions from the week. Becky for sitting in the hospital with my family before and during Gary’s surgery on Saturday, after she had been in a hit-and-run accident, it also happened to be her birthday. Kasie for being as available as possible while in the middle of nowhere with no cell reception. Tracey for “momming” me and telling me I need to go home now, instead of later. Makani, Donovan, and Sedona for making me special dinner with kale, surprising me with Its Its,  letting me have another sleepover, keeping my belongings in your guest room, taking me to and picking me up from the airport. Katisha and Kaitlyn for keeping my arrival a secret so I could surprise my mom and Gary. Michael for being my rock and understanding why I have been a bit absent these past two weeks. And last but not least all the people who have reached out to my family and I to show support.

This past week my success was measured in laughter, and meals, instead of my medical knowledge, bedside manner, physical exam skills and test taking ability. An odd, but welcome change of pace. My goal for the week was to fill in the gaps where needed.  One of these gaps was food! I put 14 meals in the freezer over the course of four days, to ease one of my moms responsibilities over the next few weeks. If you know me well, you know I love cooking.  I love finding exciting ingredients and creating meals. I hate measuring spices and following recipes (unless I am baking), instead I like to eyeball and taste test to determine what a recipe needs. I love the lack of control I allow myself in the kitchen and I love that a dish comes out different every single time. When cooking for myself, I eat about 95% vegetarian. It is a rare occasion that I buy and cook meat. This week I cooked a lot of meat and a lot of cold weather, hearty meals. This week my teacher was not a patient but instead the kitchen. I thought after a day of planning and three epic days in the kitchen I would feel burned out, but mostly I feel energized to keep it up.

One of my goals for the next five weeks is to get back into shape and keep a clean diet. I have found a yoga studio close to the apartment I will be living in that has a great deal for new students. I am looking forward to the new found energy exercise brings and to the soreness.

Callback week

Last week I was on campus all week for testing and lecture. During this week there were many indicators that I am nearing the end of my education at Touro. We took our practice board exams. Which, to say the least was enlightening. It defined my strengths and weaknesses, and highlighted the areas and I need to spend some time studying. We also started to have discussions about graduation. Every time I think about graduation I get emotional. I am looking forward to celebrating my accomplishments with my friends and family. With the people who have sacrificed and supported me through this journey.

With two rotations remaining, the time to decide what I would like to do for my public health field study has arrived. This is the only component of the MPH I have remaining, and I have decided I will be going to Cambodia. I am awaiting my placement on a project I will participate in there. More details to come on this…

Purpose

I have found a purpose. I have been doing a lot of processing trying to determine what about working with the Hoopa Valley Tribe brought me this new found inspiration. Though I am still not entirely sure, I do know many of the patients I saw need an advocate, they need someone to care for them, to embrace their flaws, someone who will give them their best work because they care. I CARE A LOT. I am feeling incredibly sad, a little heart broken, to be leaving this rotation and it is because I know I did good for the patients here. I have done more good in the last six weeks than all my other rotations combined. I am incredibly grateful for the opportunity I had at K'ima:w medical center and hope to one day work at an IHS clinic again.

Pay day

There is a phenomenon that occurs on pay day, social security day, and welfare day. All the ails of the patients that are seen at K'ima:w seem to disappear for a few days. I have experienced this a few times, but today the contrast was undeniable. For the past two weeks the clinic has been crazy busy. It's cold season, we are approaching flu season and there has been a GI virus making its way through the community. But today in the nine hours I was at work, I saw seven patients in the walk-in clinic, only two between 1:00-5:00 pm. I had time to catch up on Typhon data entry, do reading for public health and socialize with the nursing staff. To say it was slow might be an understatement.


Tomorrow is my last day at K'ima:w Medical Center and I am really quite sad about it. I feel like I became apart of the team here. I am about to make move number seven this year and community is what I am longing for all the time. I have been excited for this rotation since it showed up on my schedule 10 months ago, but I never imagined what an impact this tribe and medical center would have on me. It has inspired me and I really hope that I can find work at an IHS (Indian Health Services) clinic one day.

Although I thoroughly enjoyed working with all the providers here, I bonded with one in particular. Susan Walsh is a Family Nurse Practitioner who has worked at this medical center for 12 years. She never treated me like a student, she treated me as an equal. She had high expectations and challenged me to make assessments and plans for my patients, but was always open to discussing these things if I was unsure. She cares about her patients, wants to do the best for them, and is willing to put in extra hours to achieve that. She is also upfront and straight to the point, knows her limitations and isn't afraid to ask for help. All of these are qualities I admire about her.

And the couple I lived with, Sonja and Dan, I will also miss. They are optimistic, happy people who really enjoy having PA students live with them. They looked after me, invited me to family dinners and made sure I had all I needed out here.

I am a bit emotional about this departure, but also so excited to spend the next week with my friends in Vallejo, which unfortunately involves exams! Then it is off to ER rotation in Truckee, which means I am a week closer to a visit from my parents, and then Michael for Thanksgiving. I haven't been home since early July and haven't seen Michael for six weeks... I am elated for both visits.

Joy and Pain

As I was studying in a coffee shop in Arcata this morning I was pondering ideas for this blog post. Then it came to me. In one 8-12 hour day in clinic I can experience complete euphoric joy and also intense emotional pain. Yesterday, was one of those days. I had several patients who, when I finished I felt I had helped, then at 3:00 pm I walked into a room with a couple I would spend the rest of my day with. As a provider it is incredibly frustrating to spend a lot of time trying to diagnose a patient, ordering xrays and labs, doing chart review, spending time obtaining a thorough history to have this patient, whom you have decided needs to go the emergency room via ambulance, decide to leave the clinic against medical advice to go home and come back in the morning, simply because they are tired of waiting. And although I have to go home at the end of the day knowing I did everything I could for that patient, I still fear that they will call an ambulance in the middle of the night and not make it to the ER in time or simply fall asleep and never wake up again. I feel guilt for the unknown outcome, but hopeful that this patient will indeed have an uneventful night and be back in the morning. Most days I can leave my work at work. I can shed the emotions when I take off my white coat, but yesterday I couldn't. I have wednesdays off, so I am anxiously awaiting tomorrow morning to learn how this patient is doing. Feeling these emotions is not particularly fun, but it confirms, for me, that I love what I am doing!

Fall

Here are a few things I have thoroughly enjoyed about living in the Klamath Mountains of northern California: 

• Watching fall paint its vibrant colors along the roadway. Everyday the painting is different and I look forward to my morning drive as the sun is trying to peak through the leaves, lighting them up as if they were under a spotlight. 
• The quiet of living in the mountains. 
• Sitting in the sun reading by the river. 

I was recently speaking with one of the providers about the patient population in the clinic, although I see Native Americans all day, they are no different than any other patient population I have seen. Each day I spend a lot of my day educating patients about caring for themselves, either for an acute condition or for a chronic condition, that if not managed can drastically change their life. Each day I feel I truly get through to only a few patients, but those patients are the fuel most practitioners need to do the jobs we do. I recently spoke with a 17 year old, who was being seen for cold symptoms, he wanted to go to Oregon State but wasn't sure the best way to do it, we spoke for at least 10 minutes about the different resources he has available to him to make that happen. If he does in fact attend college in his future, he will be the first in his family. Although I will most likely never know what will come of his future, I like to think that the support I offered him will bring him a little bit closer to attending college. These types of conversations bring me peace when a patient is yelling at me because I dont think they need a Toradol shot, or antibiotics, or xrays, or whatever it is that they are wanting, or simply because I am a student and they want to see the doctor. The nice part about being a student is when I am being yelled at, I do my best to calm the patient down and if I can't, I can always get the provider who is supervising me for the day. Unfortunately, this luxury will no longer be available when I am working as a PA, I will no longer be able to use the excuse of being a student. In the same way that fall is changing my drive to work everyday, the patients I see paint my workday each day.  

Burn out...Senioritis...Fatigue

Call it what you will, but as graduation is becoming closer, studying becomes more difficult. Actually, everything associated with school, except being in clinic and seeing patients everyday, is like trying to run through mud that is knee deep, its exhausting. Packing my car, moving, Typhon data entry, minimum requirements, studying, studying, STUDYING are exhausting.  At this point, I find reading my abbreviated medical texts easiest when studying. I am so tired of reading my notes, but ultimately these are the most helpful to me at this point. Tonight I was chatting with a friend who is considering going to graduate school, she is currently taking an online course and spending hours studying, and seems really excited about. It reminded me of my excitement and fear when starting PA school over two years ago. As I was reflecting, I tried to determine when the shine of PA school wore off, and I realized that each new stage of PA school is like polishing tarnished silver, the shine comes back. Though I am lacking luster on occasion, I know I am constantly working towards the end and a new stage will start soon!

The date for graduation recently became official. Pending a few more months of school and exams, on May 23, 2014 I will receive the two masters degrees I have been working diligently to obtain. We are in single digits people, approximately 7.5 months away from graduation.

Before starting rotation 6, our clinical coordinator warned us that rotation 6 and 7 are the most difficult, because the hype of the beginning is gone, the end is near but not near enough. This is the season of burn out. I have spoken to several classmates, most of who are feeling the same way as I am. The really amazing part is when I reflect on what I have done since starting rotations in February I can reach a state of complete motivation. I have lived in six places, worked with many providers, made a lot of new friends, I have learned so much (and forgotten a lot), I have failed and succeeded, but the greatest part is I continue to fall in love with what I am doing in clinic every single day.

I recently organized all my photos from the past couple of years. During the process I came across several of my favorite quotes I found while working at Dr. Fullerton's office in Austin. We had a daily quote board, which I loved, this is one of my favorite quotes...

"A mind that is stretched by a new experience can never go back to its old dimensions."
  - Oliver Wendell Holmes, Jr.

Site visit and sutures

Well after five and a half rotations I finally had my site visit. This consisted of one of my clinical coordinators visiting at my current rotation and evaluating my clinical skills. Julia, who is also my advisor arrived in Arcata Wednesday night where I met her for dinner. It was really nice to spend some time with faculty outside of the school setting. Thursday morning she met me at the clinic. She watched me do a history, physical exam and present to my preceptor. I was pretty anxious and it took me a bit longer to get into my rhythm with each patient. She gave me some great feedback and taught me a lot during our few hours together. I also saw herpes zoster, also known as shingles, for the first time clinically. It was textbook. The patient was in a lot of pain, the rash was in one dermatome, and did not cross midline on the patients chest or back.

Friday I sutured a person (not a fake skin, banana, chicken breast or pigs foot) for the first time! I was a bit nervous, but the patient was calm and happy to let a student suture him up, and I have practiced a lot on the materials mention above. I put two simple interrupted stitches in the tip of one of his fingers. He will follow up in about 10 days to have them taken out, at which time I'll get a better look at my handy work!

Today I drove into Arcata for the farmers market and a massage. When I drive west to Arcata I try to make a day out of it because the trip takes about one hour each way. At the farmers market they had a sidewalk decorating contest. There were some really great artists out there today. I visited the square again later in the day when the crowds were diminished and all the art was completed, here are some of my favorites.

Perspective

" Your best shot at happiness, self-worth, and personal satisfaction - the things that constitute real success - is not in earning as much as you can, but in performing as well as you can something you consider worthwhile."
  - William Raspberry

The Quiet

Disclaimer: The purpose of this site, PAges from Kasaundra, is simply for me (Kasaundra) to process my thoughts during my clinical year and to include you, my readers and supporters during this process. Everything posted on this site is my opinion and in no way reflects the entities of Kimaw Medical Center or Hoopa Valley Tribe. This statement applies to this post, all previous and all future blog posts.


In preparation for my move to Salyer, CA to work on the Hoopa Indian Reservation I asked several students about their experiences here. I am living with Dan and Sonja, who have kept all five students before me, and they are an incredible couple. I am living in their garage apartment, which is well equipped with just about everything I could ask for. I have no cell service unless I drive approximately 10 miles into town and I am learning to live with only a landline again.

One of my classmates had told me she would turn on the TV low here to create some white noise because it is so quiet. I have lived by myself for several years and didnt think this would be an issue. Well, I was wrong. For the first four nights I woke up at 4:30 am, an hour before my alarm in a panic, thinking I had missed my alarm. There are no sounds of a neighborhood waking up, though I live near several other homes. There are no traffic noises, car alarms, dogs barking, or garbage trucks. The birds chirp but not until much later in the morning.

After I left San Francisco and I was settled into my new home in Vallejo, I was sitting in my room and realized how much I had missed the chirping hum of the crickets every night. The sounds of the city are much different than the sounds of the country. I am finding I enjoy the quiet, especially after a long day in the clinic. The quiet here is peaceful.

This is where I live. It is about a six hour drive from Vallejo, four hours of highway driving to Redding then two hours of two lane winding mountain roads. From my apartment, the grocery store is an hour drive either east or west on a two lane winding road. My drive to work takes 35 minutes on a two lane, winding road. It is a bit different than my commute at my last rotation, but I also find this refreshing. There are two radio stations available when I am lucky, so instead I have been listening to audio books.

I experienced the "first rain" of the season last friday. And it did rain... it poured for about 24 hours straight. I was getting a bit stir crazy on saturday morning, every time I would go outside to assess the amount of rain falling it would pick up again to a hard, steady rain. Since the first rain it has been raining on and off all week. Between the rain showers, when the sun comes out I try to find my way down to the river, which is only about a 15 minute walk from my apartment. It is so peaceful to sit and appreciate the way the sun hits all the mountains surrounding me, to listen to the  turbulent flow of the water over rocks, and to drink in the beauty of my surroundings. The river has become one of my favorite spots.

The river today during the break between the morning showers and afternoon clouds. 

Surgery

As I am nearing the end of my surgical rotation I am reflecting on the last five and a half weeks. Surgery has been stressful! In the beginning I was incredibly nervous to be in the OR, to make a wrong move, to cut the suture too short or too long. With time I have come to realize if I am doing something wrong Dr. Lanflisi will correct me. In the middle of the rotation I felt I was studying the wrong material, unable to answer any questions and was having some self esteem issues. Now, after a conversation with my preceptor and clinical coordinator and a few more weeks of practice I feel more confident in surgery. Answering questions during a surgical procedure is still challenging for me, especially when the question is completely unrelated to the surgery, I often times clam up and have difficulty articulating anything. This is partly because there are usually 4-5 other people in the OR that are quiet, not interrupting the conversation Dr. Lanflisi and I are having, this increases the pressure a bit! I think my preceptor has realized this and after I struggle for a bit he will walk me through the thinking which allows me to come up with the answer.

I have enjoyed surgery, but I dont think it is where my home will be as a provider. I have enjoyed being a part of procedures and look forward to seeing how this will be incorporated into my next few rotations.

During this rotation I have seen mostly abdominal surgeries. I haven't seen any breast cases (odd because they make up 30% of Dr. Lanflisi's practice). Last week I assisted in a lung resection for a patient that had lung cancer. The lung is a truly astounding organ. For the procedure the anesthesiologist must intubate the patient in a manner that allows him to control each lung separately, this is done with a double lumen tube.

 The photo above shows the trachea and bronchus with the intubation tube in place. See how there are two balloons, the first one (at the top of the photo) keeps external air out of the patients lungs, this allows the ventilation machine to ventilate the lungs. The second balloon in the patients left bronchus (on the right side of the photo) allows the anesthesiologist to control the lungs separately. The photo below shows photos of the inside of the trachea and bronchus, the camera is inserted to confirm the intubation was done correctly. With this intubation the anesthesiologist can "drop" one lung during the surgery to allow the surgeon to operate on that lung without it being ventilated. 

The best part of the surgery was watching the remaining lobe of the left lung re-inflate at the end of the surgery. Watching all the little alveoli pop open as the air fills the lung, bathing in the oxygen they had been deprived of.

Flying High

My excitement for this week was the result of my preceptor, however, it did not take place in the OR, nor the hospital, nor the office. On Wednesday afternoon, Dr. Lanflisi, his practice manager, medical assistant and I took his plane on a flight. We flew down to Half Moon Bay, had lunch, then flew back to make it to the office in time for our afternoon schedule. On our way home, I had the opportunity to fly the plane from Half Moon Bay to Petaluma, where we landed changed positions so his practice manager could fly and took off again. I have never been in a small plane before, I was a bit nervous, but had a great time and managed to keep my lunch down despite a turbulent return!

 The plane 

 Mare Island

The descent into Half Moon Bay

The Count

I have seen over 1000 patients since starting rotations in February! It seems crazy to think I only have 3.5 rotations remaining and that I have seen so many people in such little time. Last week I was practicing knot tying with a classmate, this is basically an exercise in muscle memory, and allowed us to share stories. Skip to 2:44, this is almost full speed with a large string, it would usually be much smaller, and is done inside a surgical site.

 Diana is also doing a surgery rotation and we try to study together a few times a week. While knot tying we were discussing our proudest moments as students and I was reminded why I love medicine. As a student in surgery I do not have a lot of patient contact, I do some pre-op and post-op appointments but nothing like what I have had in my other rotations. Most of my patient time is spent in the OR while the patient is anesthetized.

Here are a few of the moments I have experienced with patients this year that have impacted me the most:

During pediatrics we had a 13 year old female who was brought in by her father because she was considering suicide. She was thinking of cutting her self the night before but decided to give the knife to her brother. Her family was in crisis mode and desperately wanted to do what was best for their daughter and sister. At one point during the visit I was alone in the room with the patient and having been a teenage girl, I remember how awful teens can be to one another. I asked the girl to answer a few questions for me about her friends, because this seemed to be the basis of her depression and suicidal thoughts. I asked her questions like: if you have a bad day who will you call your new friend or your other old friend who is making fun of you and spreading rumors, if you have a great day and want to share it with a friend who will you share it with, if you meet a cute boy and want to gossip about him which one would you call, etc... Every single question she answered with her new friend. I then encouraged her to think about her future. We then had a long conversation about being a teenager and how hard it can be sometimes, but that one day she will look back and realize how grateful she is for her true friends and family. By the end of our chat we were both crying. As a provider I have been taught to leave me emotions at the door, but in this case I think she needed some raw emotion. We laughed and cried together and I hope she walked away with a new motivation for life. She was also referred to a therapist and family counseling. She was such a beautiful young soul, I think of our conversation often and hope she is doing well.

During geriatrics I spoke with several patients about death, many of whom I have written about, but there was one day that I look back on often. I was checking in on a patient who was in his 80's and was a healthy man until he had a massive stroke. He was on hospice care and the family didn't want to prolong his life, but wanted him to be comfortable. He was NPO (no food by mouth), had been taken off oxygen but was being given morphine to keep him comfortable. For the first two weeks he was at the facility he was able to communicate by blinking or moving his head back and forth but was otherwise completely dependent on others for his care. He was able to communicate the he was comfortable, not hungry and agreed with the choices his family had made for his care. I was seeing him to check in with the family and confirm his comfort on the beginning of his third week in the facility. I walked into the room, introduced myself to his wife, daughter and son in-law, then started to ask the patient if he was comfortable. He was no longer able to respond via blinking. His wife was sitting next to him, she looked up at me and just started crying. I got down on my knees to be at eye level with her, held her hand and tried my best to provide the support she needed in that moment. Her question was "why hasn't he left us yet, I want him to stop suffering." I asked her if she had told him it was okay to go.  Often times loved ones hang on for the people they are leaving behind and if we tell them we will be okay, they will finally let go. I encouraged her to continue loving him, talking to him, touching him, and when she was ready to let him go, to tell him she will be okay. I look back on this day and hope my words were able to provide support the family needed in those moments, and I also realize that being with patients and their families as they are facing death is a role as a provider I truly enjoy.


Surgery is exciting and I am enjoying it, but I am always nervous, I study all the time but feel I never know the answer to the questions be asked of me, basically I am stressed out a lot. I miss having direct patient care and connecting with people. I miss it because I truly enjoy it, it is when I feel most confident as a student, and it is when I feel I am learning the most from my patients .

"The only people who can own social learning are the individuals who themselves are learning each day, from one another, based on their work and in the flow of work."
    -Marcia Conner

The life of a medical student

I have been in PA school for two years this week. As I teeter in and out of a state of burn out I am frequently reminded why I love medicine and why I am ready to be a graduate and no longer a student. 

Things I LOVE about being a medical student: 

1. I am always learning something new, this also means I am always unable to answer questions my preceptors have for me. Surgery makes this much more apparent. Basically all day everyday I am grilled about anatomy, physiology, disease processes, etc. My most common answer is "I don't know, but I will look it up." It seems that the more I learn the less I know and the less confident I am about what I know. However, I am learning that often times I do know the answer and I simply have to give myself the space to come up with it and trust myself and my knowledge. 
2. Interacting with patients. As Dr. Lanflisi (my current preceptor) said, the medicine stays the same, your white coat doesn't get any whiter, what makes this profession rewarding are the relationships you have with your patients. I couldn't agree more!
3. My classmates, who have become my family.

Things I miss from my life pre-graduate school: 

1. My family, friends, and Michael. 
2. Having time to commit to self care on a regular, almost daily basis (running, swimming, biking, yoga, massage, etc...).
3. Jezebel.
4. Cooking. Michael and I had this weekly tradition for a while, we would find something in the produce section we had never bought before and figure out how to use it in a recipe. It was exciting and fed my desire to create new dishes. I love being in the kitchen, learning to use new spices and ingredients. Although I still cook regularly, I pretty much stick to the things I know.

These are some of my favorite pictures from PA school and prior in no particular order: 

Summer

It still doesn't feel like summer. I was on campus last week for callbacks, exams, an OSCE (objective structured clinical exam- it is a practical exam with a patient that is a hired actor, I am observed by a faculty member and video recorded), and lecture. I spoke with several classmates about the concept of time during our clinical year. It seems like it is flying by and standing still. A few weeks ago I wrote the month as April several times, this has been happening a lot during rotations. It doesn't feel like it can possibly already be August. I feel there are many reasons for this... 

1. I am living my life six weeks at a time.  
2. I am moving A LOT.
3. I have yet to be in a place that was hot. For spring I was in San Luis Obispo, then I moved to Seattle (at its hottest was 80), and I just spent my last rotation in San Francisco (also not known for its heat!). 
4. I am consumed by working and studying, therefore being social is pretty low on the priority list. 
5. I have yet to wear a sun dress! 

Tomorrow I start rotation 5! I will be doing surgery in Vallejo, Fairfield, and Vacaville. I am excited to be in a place I know and be close to a few of my classmates. We have grand plans of studying together! I am also incredibly nervous about surgery. I have been in the OR many times since starting rotations, however I have yet to be scrubbed in and assisting. There are a lot of rules in surgery, and this makes me nervous. Also I will have my hands inside of someones body, kind of weird to think about! 

HALFWAY POINT

Tomorrow is my last day of rotation 4 and cardiology. That means that I have completed half of my clinical rotations. Thinking about this brings joy and fear. Joy because I only have to move five more times and fear because I am expected to be an independent practitioner in less than a year. I still feel I have so much to learn before then, but I am told this feeling never really goes away.

I am moving back to Vallejo on Saturday to stay with a classmate during callback week on campus, exams Monday morning, OSCE/practical exam Tuesday morning, and class the remainder of the week. Then moving into the place I will be staying for the next six weeks and the start of rotation 5/Surgery.

Transition

During rotations there are several transitions that occur during the six weeks. The first two weeks are the "norming" period. During this time I am learning my way around the facility, the office staff, my preceptor and the new home that I am living in. I am learning what expectations are, the do's and the don'ts. I am a bit more nervous during this time. During the third and fourth weeks I am beginning to feel a bit more comfortable with all the above things and I am focusing more on learning details and continuing to learn the way my preceptor practices medicine and I am still asking A LOT of quesitons. Week five and six are the time I feel most comfortable, and that I have some idea I know what I am doing. During this time I find I am asking typical "Kasaundra questions." I have had time to think about patients, diagnoses and treatments and begin to really ask why or why not. This is the time my most thoughtful questions are usually asked. Then right as my confidence level begins to rise week six ends and I am moving to start the process all over.

Another transition has happened since my last post. This week I turned 28. Although I am not one to obsess about how old I am, 28 is going to be a significant year in my life. I will graduate from PA school during this next year, take PANCE (Physician Assistant National Certifying Exam), and hopefully find a job! And potentially move to the east coast because Michael is now working at Brown University in Providence, RI!

"They always say time changes things, but you actually have to change them yourself."
       -Andy Warhol (1928-1987)

Home

I made it through another first day this year. I am still processing the end of geriatrics, my move from Seattle to San Francisco, and the transition to living in a large city (more to come on these).  My preceptor seems like an interesting fella, he is the chief of cardiology at the hospital I am working at and has an interesting way to approach patients and physical exam but I do think I will learn a lot from him. Most of the time I will be working with the fellows who work on his service. Today I met the fellow I will be working with until the end of June. She was patient with me and in many ways still a nervous student herself, but with much more training. Many of the questions I was going to ask about showing up tomorrow morning she simply answered for me. Today I saw mostly patients who had been admitted to the hospital, we had one ER visit and then one office visit. Tomorrow I will start my day off at 7:30 in the catheterization laboratory (cath lab for short), for three diagnostic procedures to determine where blockages exist in these patients cardiac blood vessels. I am grateful I had geriatrics prior to this because I was exposed to many cardio drugs and although my patients were not as acute I feel comfortable with a lot of "cardio speak."

Leaving Seattle was by far the most difficult transition I have made since starting rotations. I thoroughly enjoyed my rotation, my preceptor, my patients and Seattle. But while there I also found myself a member of a family. My hosts, Simon and Kim were and are amazing. I enjoyed so much about living with them. Cooking together, doing yoga, playing rummikub over meals, talking about life, processing life transitions together and much much more. I find myself longing for chamomile tea, and mine doesn't quite fulfill me... Simon and Kimmy have become "my people," and in many ways I am grieving our separation.

I am also so excited to be near two of my closest friends who live in San Francisco. Geoff and Kat have been two of my sources of strength throughout this program and I have been longing for their closeness since I have been gone for three months.

"Where we love is home- home that our feet may leave, but not our hearts."
   - Oliver Wendell Holmes

I have been blessed with the gift of many homes in my life, simply because I have a lot of love for many who are spread across this country. Thanks to Simon and Kim for making Seattle home for me!

Becoming a practitioner

Dr. Addison is rarely on time, when he is all of his staff is surprised. This is quite opposite of how I like to function. With my work/school life I am very organized and scheduled. I hate being late. As a student I am basically at the mercy of my preceptors, they say "jump," I say "how high," and do it. Obviously this has its limits but for the most part holds true. Dr. Addison's staff and I have joked that he is teaching me how to be a true practitioner because when I am at work with him I completely lose track of time. I will go hours with out eating or using the restroom, and for those that know me well know this is a quite a feat. Besides teaching me a lot about medicine, Dr. Addison has contributed to my journey to becoming a practitioner by creating an environment that I get lost in (in a great way).

As a medical assistant, prior to starting school, one aspect of my job was to keep the physician I was working for as close to on time as possible. This was often quite a challenge because he got lost in his work, and when he was lost, my gentle time reminders went in one ear and right out the other. I now understand how this is possible. And it is something I love about my current rotation, I love getting so caught up in my work that I have no idea that I've missed lunch, that I haven't urinated in five or more hours and that I want to keep going!

Geriatrics

Time is flying... I only have two weeks left here in Seattle. The more time I spend working in geriatrics the more I enjoy it. Once again my expectations about clinical year are completely wrong. I thought womens health was what I would find most inspiring, and although I enjoyed it, I am really loving geriatrics. I look forward to working through charts to determine what we can change, I enjoy chatting with patients and I enjoy the challenge patients provide simply because most have several chronic conditions that must also be considered in the event of an acute problem. On Wednesday,  Dr. Addison and I had been working all day, it was 6:00 pm and we were trying to wrap up charting so we could sit in Seattle traffic to get home, but we had one more patient to see. He was a new admit and had several problems. I was trying to rapidly review his chart to determine what active problems he needed attention to, but his medical records were a mess, they weren't sequential and I was struggling a bit to move quickly. At that moment I looked up and saw two residents/patients that I truly enjoy because they are both always smiling and positive, they were eating dinner together in the common room where we were working, I could hear a woman down the hall hacking to get something out of her lungs over and over again, and I could hear someone speaking loudly (most likely because they can't hear) asking where all the chairs had gone ( I have no idea what this person was asking about). It hit me again, I am loving geriatrics and I couldn't help but giggle. I find some patients to be particularly grumpy when I ask them if I can sit and chat with them about their health, I take this as a challenge and hope that they will at least tolerate me for a bit, and they usually do. Patients with dementia can be challenging for several reasons, often times they dont even understand what I am trying to ask. For example I was asking a patient yesterday if he had diarrhea or constipation and his answer was "yea I pee and poop in there (point to the bathroom), you can go look at the toilet." This same patient wouldn't let me examine him because he had pain and didn't understand that I was trying to help him not hurt him.  Although emotionally challenging, I have found counseling families about end of life issues to be rewarding.

"You know you're in love when you cant fall asleep because reality is finally better than your dreams."
        -Dr. Seuss

Although I have no problems sleeping, my dreams are coming true and they are far better than I ever imagined.

Failure and Growth

One of the many things I learned during orientation to this PA program back in August 2011, was that I would fail, at something and that it was okay to fail. During the didactic portion of my education my classmates and I took well over 100 exams during the course of 18 months, somehow I passed all of these. Most, I even did well on. I hadn't failed anything except a few pop quizzes that I hadn't studied for prior to the pop, which didn't particularly affect my grade or my confidence because I knew I would know the information once I had time to sit with it and study it appropriately. Although I do not necessarily fear failure, I fear the consequences of failure. These are the things that keep me nauseated waiting for an exam grade. During didactic year these consequences meant having to stay during our much cherished breaks to retake an exam, during rotations this means returning to school to retake the exam. The stakes with retakes are higher, and we are required to receive a higher grade to pass.

Two weeks ago I failed an exam. I felt under prepared for both end of rotation exams (this was a common theme among all of my classmates) and I think it was because these were the first EORs we were taking. We didn't know what to expect but we did know there was A LOT of information on each one. In classic Kasaundra style, it took me a while to process. I was studying hard and it took a minor incident totally unrelated to the exam to push me over the edge. I finally broke. I felt vulnerable and scared and alone. I sent Tracey (clinical coordinator) an email because if I called I would cry harder, asking for guidance and encouragement. As I expected, she was amazing and said the words I needed to hear/read. Two hard weeks of long clinic hours, a lot of studying and a little sleep I had to retake this exam. I had to fly back to the bay for the exam monday, fly back monday night to be in clinic on Tuesday. The consequences of a second exam failure are high, I would fail the rotation and have to repeat it before I would receive my diploma in a year. After my exam I still felt very nervous.

Yesterday I had a great day in clinic. I was at a facility for the second time, it was nice to be in a semi-familiar place. The patients as always were great to talk with, I was able to follow up with  two patients I saw last week, and they both seemed to be doing better. In the afternoon I was reading a chart of a patient that was at the SNF (skilled nursing facility, we say "sniff" for short) because he was hospitalized for bowel impaction/constipation and he needed to figure out his bowel routine before returning home for his wife to care for him. He was on a medication called GoLytely, used for bowel prep/cleansing or in the case of severe constipation to induce a softer bowel movement and possibly diarrhea. If this med was given to anyone without constipation it would cause severe diarrhea. I was giggling a little as I was reading, I dont know why but the name of this medication made me very happy. Just then, I heard a woman in the hall (who I cannot see) yelling "JUST LET ME SIT DOWN," the physical therapist calmly says "you have 10 more steps until you are at the chair to sit down." Again "WHY WONT YOU LET ME SIT DOWN." And I lost it, I realized in that moment that I am falling in love with geriatrics. I was giggling loud enough that Dr. Addison stopped what he was doing to see why I was so amused, I explained and we had a nice heart warming giggle together. My day was great and a distraction for the wait until my exam grade was posted.

I PASSED! I have proven competency in pediatrics and obgyn and never want to be in that boat again. I feel this failure has allowed me to understand how grateful I should be for all the times that I have done well on an exam. I have learned how much I need to be studying in addition to clinic hours. I have learned that I have a rally of cheerleaders standing behind me, and just how grateful I am for their support. And I have learned that it is okay to fail but I dont want to do this again. I have gotten back up, wiped off my scrapped knees, put my ego in check and these wounds will heal with time and some care.

I was looking for a quote to end this post and there were a lot that spoke to me, but this one gave me a  wide smile because in one year I will be graduating, I am looking forward to that success!

"Failure is the condiment that gives success its flavor."
 -Truman Capote

Death and Dying

This week, for the first time, I spoke with a patient about dying. She has metastatic colon cancer and has fought the disease for a long time but was put on hospice care a month ago. After reviewing her chart, I went to speak with her. Last week she was doing okay, this week she is "ready to go" she tells me. She asks me "how long until I can meet Jesus?" We continue to discuss her family and friends and she tells me she is too exhausted to see them anymore but they keep showing up. We chatted for some time, every few minutes she would ask me to feed her some ice for her dry mouth. As our conversation would pause I realized how at peace she was with this decision she had made, the decision to stop living, the decision to die. In her presence I was surprisingly at peace with her decision as well.

In my life I have had limited exposure to death. In school, when we discussed it I usually became anxious, I would think "this is going to be so difficult and stressful." To my surprise I was completely at peace with this conversation, I was grateful I could be there for this patient to support her through this decision. Speaking to Dr. Addison after I finished my history and physical before he went in to see her, I asked him how he answers the question "how much longer can I expect to hold on?" When she asked me this question I was very truthful, I lack experience and have no idea how to estimate the amount of time a patient will continue to live. He says he decides how much longer he thinks and adds a few weeks.

Throughout my clinical experience I have found many things that are not the way I had expected them to be. In OB/GYN I expected miscarriage to be really challenging for me emotionally, however it was quite the opposite. The times I was most emotional was when parents heard the fetal heart tones for the first time or saw their baby on ultrasound. Their joy filled the room and me, several times to the point of holding back tears. That was unexpected. In pediatrics I spoke extensively with a 12 year old female who was depressed and considering self harm and suicide. She had great family support, but she was unhappy socially. We talked for a long time about friends and by the end of the conversation she was crying and I was fighting hard to keep my tears in check. I know life is never how I expect it, this is what keeps it exciting. I am sure my emotions as a provider will continue to surprise me, and I am okay with this.

Support

I am so grateful for all the support I receive from my family and friends. I have also met some pretty amazing people in the past three months while on rotations. People I may never see again, but for whom I am very grateful to have met. These people who have opened their homes, practices and lives to me will forever be apart of my journey to becoming a practitioner, for this I have so much gratitude and appreciation. I am currently living with my classmates parents, who are amazing! I have only lived with Simon and Kimmy for a week and they have been stellar hosts. They have accepted me into their home as though I am their family. We have been to yoga together, cooked meals together and played rummikub. I am feeling full of love and happiness!

DIY

Today I completed a Do It Yourself project. A few weeks ago the shifter button (the button you press to change gears in an automatic) in my car broke into several pieces. I was slightly annoyed, but continued changing my gears by pushing in the pieces, which were still functioning. I had an appointment already scheduled at Honda to have my brake pads replaced, so I asked for a price quote... $165.00. I decided to do a little research of my own, found the part on Amazon for $15 and a youtube video to demonstrate. The day after I arrived in Seattle I was at a grocery store ready to head home when the shattered pieces that were still functioning fell apart. I couldn't figure out how to get my car out of park. I used my nail clippers to fish out the broken pieces of plastic and was able to manipulate the inside of my shifter nob to drive home. For the past week it has taken two hands to put my car in gear! Humorous? Yes, but I received the part in the mail a few days ago, the replacement took me less than 15 minutes and IT WORKS! The sense of joy I felt once completed was great, I wanted to call Honda and laugh about the $165 quote. Instead I had a little extra pep in my step and went back to studying.

Although not a DIY project, today I completed my first injection on a patient. And it was easy. I am so grateful my first injection was not on a child who would have been screaming in pain, it was instead on a woman with dementia who sat still and quiet. It was as if I hadn't touched her. I also saw a patient today who attended Kansas State University, I know this because he had a purple mug sitting on his shelf. My Nana and Grandpa live in Manhattan and we had quite a conversation about the school and his accomplishments while there. My favorite part about geriatrics thus far is spending time with patients. Ultimately most of them just want to feel they have a voice and are being heard by someone. Interestingly, my greatest struggle in geriatrics thus far is being heard by patients. Many of my patients are greater than 85 years old and about half are 90+, therefore many of them are hard of hearing. When I speak louder my voice tends to increase in pitch as well (this is a common mistake most people make when speaking to people with senile loss). Presbycusis/senile hearing loss is associated with high frequency loss, therefore even when I speak very loudly, many of my patients still struggle to hear me.

" One of the most valuable things we can do to heal one another is to listen to each other's stories."
 - Rebecca Falls

The First Day

After a crazy week of traveling back to Vallejo to be on campus for two days, the long drive to Seattle, and two clinic days with my new preceptor I am starting to feel settled again.

I was researching quotes about first days (because during this year I will have eight first days, thursday was my third) to end the blog with and a found several with this concept. Each day is a once in a lifetime event. I can't say I have really ever thought about life in this way, however clinical rotations has made this very apparent. I am constantly learning new things about medicine and becoming a better practitioner. I am making mistakes and receiving gentle guidance from my patients and my preceptors on how to improve myself, and I LOVE IT! I am so grateful for all the time and energy my preceptors are willing to put into my education. I can't think of another time I have ever received one on one training that was this in-depth.  I have spent two full days with Dr. Addison, he picks me up from the office around 8:30 and we are off in his car for the day. When we are done for the day he still has to return me to my car, thus leaving us a lot of time for discussion.  We have discussed different diagnoses in detail, politics of medicine and running a successful practice, office politics, and the list goes on. I am excited to see what the next five weeks has to be discovered.


Thursday was my first day of Rotation 3, here in Seattle I will be working in geriatrics. Each day of the week I will be at a different skilled nursing home, assisted living facility or making house calls with Dr. Addison. Thursday we spent the entire day in a skilled nursing facility covering for one of his partners who is on a sabbatical. This was a great introduction to geriatrics because all of these patients were new to Dr. Addison so we did A LOT of chart review. I found this to be particularly helpful because in pediatrics and obgyn the charts are not as extensive as in geriatrics. I saw two patients on my own thursday. One was a new admit, she recently fell and broke her femur and will be in this facility until she is able to bear weight and be independent again. I spent about 45 minutes with her doing an extensive intake and physical exam. Right before I went to go see her Dr. Addison gave me her most recent labs and told me to "figure it out." What he wanted me to figure out was why her ESR (erythrocyte sedimentation rate) was greater than 140. ESR is generally a marker for inflammation, but is rarely >20. (To read more about ESR, click here). After I saw her I returned with Dr. Addison, he did a much shorter physical exam then asked me what I thought. I was still puzzled by this ESR. He had made a diagnosis, then as we discussed the ESR and her symptoms, everything changed. His demenour regarding her diagnosis changed. Instead of a furuculosis (a bacterial infection) being the cause of her rash we were suddenly discussing vasculitis. Her hematoma was no longer just a hematoma but possibly another symptom of vasculitis. He walked me through his thought process and asked how I would treat her, this I knew... Prednisone!

Friday we spent the day making home visits all day. I see why as a geriatrician it would be easy to be overweight as many of our patients had treats for us. My favorite was homemade pear pie and it was delicious!

The weather has been absolutely beautiful since I arrived, in the upper 70's to 80's and sunny. Today is my first day of Seattle rain and it is supposed to rain all week. I had a beautiful welcome to Washington and now I get to experience what the weather is really like here!

"Each new day is a blank page in the dairy of your life. The secret of success is in turning that diary into the best story you possibly can."
  - Douglas Pagels

Trust

A few weeks ago my rotation schedule was falling apart before my eyes. Boston was canceled for reasons unknown to me, NY was no longer a possibility and I received the dreaded email from Tracey (my clinical coordinator) saying she was going to be reworking my rotation schedule. I was holding myself together but was pretty nervous. I trust Tracey, she is amazing at her job and truly cares about ensuring we receive a great clinical experience. Tuesday I received my rotation schedule with a few changes and one hole. This hole is my next rotation... thats right, I am moving in one week and I have no idea where I am going. There were a few changes to my schedule, rotation four will now be cardiology in San Francisco at a Sutter clinic, where it looks like I will receive inpatient and outpatient exposure, and I am no longer going to Las Vegas (unless of course that is where I am going next). I am happy with the changes in my schedule but wish I knew where I will be moving next, mostly so I can find a place to live...

On a lighter note. This week I saw a patient who was menopausal, her last period was over two years ago (by definition menopausal is when a female has not had a period for 12 consistent months). She had a laundry list of complaints, but her entire physical exam was normal. The most amusing part of the visit was when she decided she might be pregnant and that is why she hasn't had a period in TWO YEARS!!!! She also had no other signs or symptoms of pregnancy... I might have had a good giggle when I was a safe distance from the patient room. Sometimes I cannot comprehend where patient complaints come from, but the majority of the time they are warranted complaints that need further investigation. We did order a pregnancy test and several labs to confirm she was menopausal and canceled her procedure because of the possible pregnancy. Patients keep medicine interesting in many ways including, but not limited to the following:  when they present with a condition that is not common, when they present with a common condition but in an uncommon way, when they have absurd complaints that are normal physiology (these usually require a lot of patient education) and when they let their minds wonder and come up with very unlikely explanations for symptoms they may have.

My last day with Dr. Lickness is Tuesday, I drive back to the bay Wednesday, call backs and end of rotation exams are Thursday and Friday. Block two is under my belt, time to pick up and move on again!

Quantum superposition

My homework for the weekend from Dr. Lickness consisted of many things including Schroedinger's cat, a thought process based on quantum superposition. Which states something like this... a physical system, such as an electron, exists partly in all is theoretical states simultaneously, however when measured it gives the result of only one of the possible states.  So bring in Schroedinger's cat. A cat is placed in a room (or a box) with a radioactive element (these are unstable and likely to breakdown), and a Geiger counter (a particle detector that measures ionizing radiation) that is connected to a device that will release cyanide gas when radiation is detected. In this state the cat is dead and alive until the experimenter opens the door to determine which state the cat is in. However, by opening the door the experimenter has interfered with the experiment. Therefore the expriment must be described in reference to the actions of the experimenter. Schroedinger's motivation for this paradox was to criticize Copenhagen's interpretation of quantum mechanics.

Mind blown...

Yoga

On saturday afternoon I attended my first yoga class since my departure from Austin in July 2011. It felt so good to be back. I took a gentle class to ease back in to my practice. I had a great instructor that played music by many of my favorite artists. In the middle of the class I was in a deep twist and one of my favorite songs came on. I started to get emotional. I have had many profound moments in PA school but nothing compares to caring for yourself. I bought an unlimited package and have been back to another class. I forgot how at ease I can be with stress when I am taking yoga classes. I feel a sense of balance that I have been missing in my life. My mind and body are happy and calm!

Transitions

As I begin to do exams in the specialty of obgyn there are a lot of things I am reflecting on. Each specialty is different, each practice is different, each specialty requires different history questions and physical exam skills. Sometimes something as small as pulling out the foot rests for a pelvic exam can be challenging and take three times longer than it should. I am hoping as my clinical year continues these small challenges become fewer and far between and I am able to use my time more efficiently. Until then I will continue to clumsily find my way to the table controls, the light switch, the speculums and the stirrups. I guess I would rather have issues with these things and perform a good physical exam than vice versa.

Interesting fact

Dr. Lickness gives me homework assignments. Yesterday it was a history lesson after I told him I would be heading to Boston for my next rotation and today some fun facts.

Todays homework assignment: why is everything in the OR including your scrubs blue or green?

The answer: Prior to the 1950's all OR attire was white, to symbolize cleanliness. The problem with this was that in a very brightly light OR with all white scrubs and linens, surgeons eyes would fatigue, resulting in eye strain. Therefore surgical attire was changed to light blue or green, to create a high contrast environment. The inside of the surgical field is varying shades of red. Blue and green which reside on the opposite side of the color wheel create contrast therefore decreasing the strain on surgeons eyes.

Moving on... Pediatrics, OBGYN and Pismo Beach

Life has been pretty crazy since last week.

As a parting gift from pediatrics one of the kiddos finally gave me a GI bug. It was minor and I avoided vomiting with some OTC meclizine but it knocked me out for most of the day Friday. I really enjoyed pediatrics, it is challenging in many ways that other areas of medicine are not. In school, we learned a very organized physical exam, typically from head to toe. However, in pediatrics there is no such thing as a head to toe exam. You simply examine the area the patient is presenting to you and work around that. For example, if you walk into a room to a baby that is sleeping, examine the abdomen, heart and lungs first (all the exams that you need the child to not be screaming for so you can hear through the stethoscope), then start moving the baby around and hope you can finish most or all of the exam before you have completely agitated them. Also most peds patients don't have the ability to tell you what they are feeling or do they have the intuition to understand why they maybe feeling the way they are, this can be challenging. As a practitioner when you are treating a child you are also treating their parents, in case you dont understand, that is TWO+ patients per visit. One of the greatest physical exam tools I learned in pediatrics, if a child will not open their mouth to allow you to see their throat, simply stick a tongue blade between their teeth, slowly push it towards their throat and  gag them. The gag reflex is strong, if you gag someone they WILL ALWAYS open their mouth. Although I did not enjoy eliciting this in children, it is very effective.

 Saturday I packed my belongings into my car and moved down to Pismo Beach. I arrived later in the afternoon just in time to see an amazing sunset. I went to bed early as I was still recovering from the GI stuff and needed to be well rested for the day of work I had ahead. I woke up early Sunday morning, found a local coffee shop near Shell Beach and started the long day of work. All of our assignments for school are currently submitted via mail and must be postmarked by their due date. I had three large assignments due Monday and I had been working on all of them but also procrastinating on all of them.

Yesterday I had my first day of OBGYN. I started the day with hospital orientation, walked into the office around 10:15, met the office staff and Dr. Lickness and off we went. We made three trips to the hospital yesterday in the hopes that twins would be born before 5:00 pm, after two trips to the hospital and two false calls the twin boys were born vaginally at 5:17 and 5:30 pm. It was a crazy and exciting first day!

Day two I saw another baby boy born via Cesarian section and two tubal ligations. My lunch was a sprite that I drank at 2:30 pm simply because the OR was running behind for the second tubal that was scheduled and Sprite was the only item available in the OR lounge.

Although seeing babies born is really exciting, my favorite part of the last two days is seeing a couples reaction the first time they get to hear their baby's heart beat or see their baby on ultrasound. The joy they feel fills the room and has brought me to near tears twice. Although I have been told that my empathy for others will be a challenge for me as a practitioner, I have yet to experience this "challenge" and I am so glad that I have been allowed to share these amazing moments with patients.

"Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around."

- Leo Buscaglia

Self defense

Last thursday night I traveled into San Francisco to go to a self defense class with Kat. I thought it would be smart to have some idea how to defend myself since I will be moving to a new city every six weeks for the next year. Although I am generally very aware of my surroundings, which is the key to prevention, I thought I would ease some of my anxiety (and my mothers) by taking a self defense class. The class was great, we practiced yelling STOP as loud as possible ( I was able to wake up my cheerleading yell after allowing it to sleep for about 10 years) and learned several maneuvers to use if ever attacked or in an uncomfortable situation.

Another form of self defense I will be learning throughout the clinical year is how to protect my heart while allowing myself to be available to emotionally support patients for the brief time I have with them. One of my professors described this as being like a teflon pan, having the ability to hold the space while with the patient but allowing the emotional aspect to slip off at the end of the day. In essence being able to leave work at work. I know this maybe a challenge for me as a provider because I am very empathetic but, I am hoping I can recognize the importance of my mental health, and that to best care for my patients I must be able to perfect this process.

This week I have been doing a lot of counseling with parents and their children regarding diet, exercise and weight. This is an aspect of being a practitioner I have come to realize I really enjoy. I feel like these parents hear me, at least for the ten minutes I am speaking to them. The real test comes at the follow up visit to determine if they have made the changes with their families to lose weight and gain health. Unfortunately, I will not be here in four weeks to determine if there has been any change.

I am seeing most patients on my own each day, Dr. Mahdavi then comes in the room to check over my work and add to anything that I might have missed. Although I have made several wrong diagnosis, I have made several right ones. Dr. Mahdavi is very positive and praises me for my efforts (right or wrong) and will quietly mark out my wrong diagnosis. He is  a great teacher and I am so grateful for my time in this clinic!

Paper

Today during my massage my therapist and I were discussing paper. I love paper. I love opening a book, it fulfills my sensations. The feel, the smell, the weight in my hands. It is one of my favorite things. (I should say that my love for paper is also a point of conflict for me because I also an environmentalist). I hadn't thought about my love for paper in a long time and enjoyed sharing this with Kim.

The hospital that Dr. Mahdavi's office is in went live with their new EHR (electronic health records) system on friday, therefore the hospital will have NO more paper charts. Tuesday I attended a lunch time talk that served to answer questions and address fears or frustrations. There was a physician who was particularly agitated because he wouldn't be able to dictate all of his notes and would be responsible for typing progress notes into the system. Most of his agitation was stirred because he is unable to type, or has never had training in typing. Upon further thought I realized I will be entering the medical field at a time of great transition for many practices and hospitals. Although I have been around computers my entire life and have had exposure to three different EHR systems to date, EHR is very scary to some medical providers because they have never used a computer. I wonder if they will achieve the same level of efficacy they had with paper charts or will they end their careers being frustrated with the new system they were required to conform to.

Some statistics from HealthIT.gov

• 79% of providers report that with an EHR, their practice functions more efficiently
• 82% report that sending prescriptions electronically (e-prescribing) saves time
• 68% of providers see their EHR as an asset with recruiting physicians
• 75% receive lab results faster
• 70% report enhances in data confidentiality

So, although this process maybe scary, it seems there is a lot of data available that supports the change. In addition, it is required that all medical records be electronic in the US by 2014. 

Week Three

This has been quite a week. Last weekend I moved out of my apartment, most of my belongings are being housed in a storage unit in Benicia and I have moved in with a family in Brentwood. My morning commute was 25 miles and is now less than 10. Although I feel settled I still have a lot of stuff to sort through and organize for storage. Tonight I am headed to SF to eat crab and make smores, a much needed break with friends. I realized that I am trying to have as much friend time as possible while I am local because in three weeks I will be moving south to San Luis Obispo.

It is hard to believe that I am half way through my first rotation. I am starting to see well child checks on my own and continuing to observe episodic visits. I am continuing to learn so much. Yesterday while doing laundry at the laundry mat I was brushing up on anemias and realized I still remember quite a bit, however a lot of it seemed brand new (we learned this 1/2012), and this is the reason I will have a year of clinical rotations, to cement the information I learned during the didactic year.

Yesterday we saw a kiddo who was 6 and was diagnosed with avascular necrosis of the femoral head (the hip joint). The diagnosis was made early in the disease progression, in an effort to save the head of the bone from needing replacement now, the child will have to be non-weight bearing on crutches for 4-6 weeks. I can't imagine having a 6 year old who is not allowed to run and play for 6 weeks, sounds like a form of torture for parents, and believe me this kid had some energy. I was speaking with Dr. Mahdavi after the family had left and asked if he would consider sending the family to a session with an occupational therapist to find activities the family/child can do during this time of restriction. Dr. Mahdavi said it was a great idea and called the father immediately.

And I will leave you with another quote, simply because my dreams are coming true...

"All our dreams can come true - if we have the courage to pursue them."
            -Walt Disney