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