Family Practice, continued

I stayed home today with my son who is sick. My wife had to travel to California for work so it's another boy's day home.

The clinic I am at is very interesting. There are so many chronic pain patients - I can't believe it. 75% must be on vicodin, percocet or MS contin. I feel that the vast majority need these medications but there are a handful that just piss me off. When you've seen these type of patients you'll know what I mean but until then it is difficult to really grasp what these people are like. Manipulative, mean, argumentative, and nasty. I hate dealing with these people. I do mean Hate. And their sense of entitlement regarding coming in late, demanding early refills, refusing to comply with the requirements of continued care and lack of decent interpersonal skills makes being around them a chore.

On a similar note, it seems that the majority of our patients are heavy smokers. The stench of cigarette smoke they carry on them is so overwhelming that I seem to be able to smell it hours after I leave the clinic. The thing is that a lot of them don't want to quit smoking, but they come in frequently for URIs, HTN, asthma and COPD needing O2 and med refills. They complain about all of their health problems and not having money to pay for decent food or health care yet they spend $100-$300 a month on smokes! My parents are heavy smokers and I grew up with the chain smoking mentality. I also realize that smoking may very well be one of the most difficult addictions to break. These people (including my parents) still piss me off with their lack of resolve, self-control and common fucking sense. If you are going to smoke 2 or 3 packs a day, what in the hell good do you think O2 or inhaler is really going to do for you? The spectrum of the human condition and experience is infinitely vast and often impossible to relate to. I "get it", but sometimes I still don't really "get it."

Family Practice

So now I have started a FP rotation in a rural mountain town. Today was stressfull but mostly draining. The PA I am with got into an argument with a patient with no patience. She complained he was taking too long and he told her not to give him any crap today. The argument ended with her refusing to quit smoking or follow his advice and with him frustrated and furious. He walked out of the exam room and left me to smooth things over with her which I was able to do for the most part after 20 minutes. We then had a lady in late her late 60's complain that after a year and a half of practicing anal sex with her boyfriend she wanted to know why her perieneum hurt soo much and if we could fix it. We tried. I was left to counsel a young man with pneumonia who decided to break down crying to me about his grandma and aunt's ilnesses and concerns. After I got those under control and returned with his rx for a chest x-ray and antibiotics he broke down again about the feelings he had for his high school sweetheart who resides in another state and who he hasn't seen in years. He feels they still have a relationship but isn't sure and as a result has put off having sex with a few of his cousins until he knows for sure what is going on with his "girlfriend." This guy in his 30's was sobbing and I was the only one there to talk to him about his nutty-ass problem. Add to this some drug-seekers and "I'm and hour late but you need to see me anyway" types and I left there drained and wanting to have a few stiff drinks. My real wish was that there was a chlorox handi-wipe I could stuff into my skull and wipe my brain clean. Some cheap red wine will have to suffice.

OB/Gyn continued

I have really enjoyed this rotation. I have scrubbed in on a bunch of surgeries, assisted in few, gotten a couple intubations, done a bunch of pelvics and a couple paps and closed a few lap incisions. Tomorrow I scrub in on a pretty serious case of colpoceisis. Usually performed on frail, elderly women with severe prolapse of the pelvic organs and with no use for their vagina, the colpocleisis involves denuding rectangular portions of the cervix, everting and sewing the vaginal lemum closed. The denuded portions are then in contact and heal together, sealing it almost completely.

My doc has spent some time helping me with knots and suturing and given me some advice on confidence (mine and other's in me). Everyone at the practice, in the OR or on the labor and delivery deck has been friendly and helpful. It goes without saying, but I go out of my way to thank everyone for helping me with anything, and I make a huge effort to help with transferring patients or whatever needs to be done. Being helpful and friendly goes a long way in making rotations go smoothly.

The master's program work is an additional grind that I'd rather do without. But since my masters is health administration I don't have a clinically related master's and need this for the future, I think.

The end of this rotation marks the midpoint of my final year. I am 6 months away from graduating. Yikes.

Ob/Gyn Rotation

The first week of my Ob/Gyn rotation is complete. It has been interesting and, dare I say it, fun. I spent day 1 with an NP. No "hands on" exams but I saw a bunch of cervices and observed all the exams and an endometrial ablation. Only one woman didn't want me in the room for her LEEP. She was in fact the only person to decline my presence all week long. Tuesday and Wednesday were half days in surgery and half in clinic. On tuesday the lovely Austrailian anesthesiologist allowed me to intubate the two patients in the OR and the surgical assistant gave me pointers on subcuticular sutures and allowed me to close on my side after the doc scrubbed out. Wednesday didn't bring any intubations but I did get to do some minor assisting in the OR and helped close. Thursday was call day and the doc and I rounded at the hospital, did a hysterectomy, had a vaginal delivery and c-section with twins (major, gushing volumes of amniotic fluid). I also performed bimanual exams on the surgical patients under anesthesia. Today was a clinic day, mostly OB checks, so not nearly as exciting. The Or has its own rules and etiquette. I contaminated myself twice and had to get a sleeve (which is better than having to scrub out!) and I felt like a loser but I am getting the hang of it.

My wife went on a girls-only weekend to celebrate her 40th birthday so it is just me and my son for the weekend. I see junk food, a birthday party and a football game in our immediate future. And if he ever takes a nap I have a ton of work to do for my masters program.

Ads, and What do you want to know?

I've added advertisements to my blog to try to make some spare cash. I realize it isn't in the best taste to do so, but figure if I can make any money to supplement my school loans and my life a little easier then it's worth it. If tou have an opinion one way or the other let me know. And please feel free to click on the ads to help me out if you wish. That wasn't in good taste either but hey, I am a student and am exempt from rules of decorum outside of the clinical setting.

If you have any questions about PA school, clinicals or medical equipment for school please let me know. If you'd like my perspective on an issue I'd be happy to oblige. If there is something you had hoped to get from this blog but haven't let know. Maybe I'll ignore it or get all passive-aggressive on you. Maybe I'll do something about it. Mostly I want to do this in worthwhile way - I really don't feel the need for futility in my life. Thanks.

Psych

Psych is very interesting to me. So little of it is based on science. We don't know for sure why mental illness develops, we don't know why exactly the drugs we use to treat mental illness work, or work in some and not others. The people I am seeing on an outpatient basis are for the most part marginally functional. Most don't have a job and have a stream of ruined relationships trailing behind them. If they have kids, they are often no longer in the picture. Alcohol and drugs abuse are a given at some point in their history. If the law hasn't been involved in their life it likely soon will be. Many with scizoaffective disorder will never be productive members of society. The best hope is that they will be able to function, avoid the law and substance abuse and perhaps hold a job of some sort. Bipolar is pervasive and yet often misdiagnosed. ADHD seems to be in the water here - so many of the adults and children have been diagnosed with it that I wonder if I don't have it. Many of the adults with ADHD, as is common, have a history of self-medicating with cocain and meth. In fact, if an adult w/ suspected adhd has tried either and says that they felt normal when using, that is almost pathognomonic for adhd. I've seen a few medical hold placed on patients - for 72 hours they are under the control of the state.

The inpatient setting is astounding to me. The trend in the US has been to close state hospital and to place the mentally ill in nursing facilities. Now these folks are just tossed in with grandma - they have theri own secure locked portion of the building, much akin to an Alzheimer's ward. The folks here are so ill they have little hope living with their family let alone on their own. schizophrenia is commonest illness in this setting. Since these patients were never compliant with their meds and were often using drugs and committing petty crimes on the street. Some can carry on a conversation, others are psychotic that they can't even look you in the eye. Some find their symptoms troubling while others revel in the hallucinations and delusions that come with their disease. Some are as young as 25 or as old as 75. When dementia sets in these patiens can be moved to less secure setting as they pose a decreased flight risk.

I still haven't actually treated any patients or written an prescriptions on this rotation - I am still a fly on the wall for 99% of this rotation. The docs are all nice. One didn't know what MRSA was when it was brought up in conversation with patient. He's been in practice for 40+ yrs and was able to determine it was an acronym for something however. Another doc defers to me for most medical questions from a patient. The other like to pimp me occasionally but her answers are usually not correct. Finally, the one I with tomorrow is very bland and soft spoken. Dowdy and unengaged would be other terms to describe her. I find it interesting how little the psychiatrists actually want to talk to their patients. At this point they have become dispensers of drugs and little more.

Mental Health Rotation

This week I started my mental health rotation. It has been interesting to see really sick people with some unique stuff going on. It has always interested me as to how the mind can work so in some and so terribly poorly in others. The folks we've been seeing are truely in need of al the care they can get. We have PTSD w/ conversion, schitzo-effective disorder, psychosis w/ delusions and numerous bipolar on top of your run of the mill depression and anxiety. The drawback is that since these folks are so sick there is no chance of me jumping in to monkey around. The other drawback to me is that since I am only working with psychiatrists, I don't get to see any of the couseling aspect of their treatment. We only get symptoms and prescribe/change medications. I guess as a PA I wouldn't be doing any sort of couseling to any extent, but it still interests me more than doling out meds.

The face is back to its normal state. My skin looks better than before I started the fluorouricil treatment in fact. The doc also went in and cut out a lesion I had for a while that was multi-colored and irregulary shaped. It ended up being seborrheic keratosis but I was tired of having people tell me I needed to get it looked at. It is gone now and in its place is an inch-and-a-half long scar that is too fine to really notice. I was hoping to add to my collection of scars but I am afraid this one won't really count.