Since our comprehensive examinations, we have been on our LAST ROTATION, preceptorship. It is bitter sweet because it is the end of our long journey, but also finally a sign of accomplishment. At this point we are expected to be taking on our own patients, creating our own set of orders, and determining appropriate course of stay and therapeutics. Originally, when I thought about preceptorship, I was nervous. Nervous that I wouldn't be able to work as independently as they wanted, nervous that I would have to play "catch-up" with everything that I should know and somehow didn't. After just a few days on site I realized that I was more prepared than I ever thought I would be. Common cases were great because I was getting more familiar with diagnostics and treatment regimens. Complicated cases were still not easy, but not impossible. My first ER rotation was in July, and I was no where near as proficient as I was during my preceptorship. Clearly all of the hours and studying put in over the past 10 months paid off.
This is it! Last week our class took our final examinations before graduation. Below I highlighted a little about each of them.
Clinical Competency Examination (CCE):
As mentioned before, we have patient simulation cases where we get to practice our skills independently on actors before we are on our own. As we have been doing this all year, these cases were not terrible difficult; nevertheless, they are always nerve racking when you are being graded so heavily. We had three cases one day and three the next.
2 cases were "communication" cases, these types of cases are typically counseling of some sort, tobacco cessation, weight loss, delivering bad news of some kind, abuse, domestic violence, and many others.
4 cases were typical medical cases where patients presented with a common chief complaint where we had to get a problem focused history and physical, then provide the patient with our plan.
These cases were not purely based on our accuracy, but also our ability to communicate and converse effectively with our patients. We got "points" for asking how the illness impacted the patient's life, if they have any questions, for checking understanding of the assessment and plan, and for summarizing our plans at the end. We were graded by the patient actor, however, we also wrote a SOAP note upon completion of each encounter for additional grading. Since this was a requirement for graduation, it was considered a "pass/fail" examination. Each of us were notified a few days after the cases on our status. (Let me tell you, I didn't think I could be happier after getting the email stating that I passed and did not have to repeat those cases :p)
Comprehensive Examination ("Mock Boards"):
As you may know, upon graduation, we have to take a national competency examination known as the PANCE. Our program prepares us for the boards by hosting their own examination similar to those boards two months before graduation. The PANCE itself is 300 questions, but our Mock Boards were 210. Before the exam I was extremely nervous, there was so much riding on this exam. Like the CCE cases, we need to pass to graduate. Luckily, it was only about two days before we were notified about our status for that exam. Just when I thought I was happy to pass CCE, I was much happier to find out that I passed the Mock Boards, especially because this is supposed to be the simulation for the PANCE and has been a very good predictor for estimating which students will pass come June.
Finally, all of the high stakes exams are finished for now, and all I have to focus on is studying for the real exam... the PANCE! Come June, I hope that I will be ready! But until then, I will keep chugging along, studying daily and focusing on my last rotation (The Primary Care Preceptorship) in Emergency Medicine.
Unfortunately, my CTS rotation has come to a close; however, I have not only learned a ton, but also was able to practice a ton of skills. Thanks to an amazing team of PAs and doctors, I was able to try new things that I never thought I would even be allowed to do on rotation! As exciting as it was, I would just like to overview some general things in regard to cardiac bypass.
Common Indications for Cardiac Bypass
Left Main Coronary Artery Occlusion >50%
Stenosis (hardening) of LAD or Proximal Circumflex >70%
3 vessel disease with or without angina, or with Left Ventricular dysfunction
The Surgical Procedure
Depending on how many arteries are occluded, a certain amount of vein/artery autograft is needed. At many hospitals the PA is primarily responsible for harvesting the vein or artery from leg or arm. Before now, this was performed in an open procedure with an incision alongside the vein to remove it. Now, most of these harvests are performed endoscopically with a scope designed specifically for vessel harvesting. With this scope, the incision in limb can be much smaller; in most cases that I was in, it was no more than two and a half inches. Once the vessel is harvested it is prepared by clipping the branches closed and repairing any possible holes/areas of potential leakage.
While the vessel is being harvested the surgeon is opening the chest and preparing for cannulation to the pump. If needed, he/she will take down the mammary artery for anastomosis. Once the PA is finished harvesting he/she returns to the chest with the surgeon and assists with cannulation. The purpose for the pump is to allow for blood distribution to the rest of the body while the heart is still. Essentially, the pump machine acts as the heart for the rest of the body. During this process the heart is cooled to allow for complete asystole and preservation during the bypass.
The bypass begins distally by attaching the autograft to the area distal to the occlusion (to allow for blood flow to the areas previously restricted due to occlusion and essentially "bypassing" the occlusion). Once all the anastomoses are attached distally, the autografts are attached to the aorta (proximally). Very small sutures are used for vessel anastomosis which requires the use of magnifying lenses worn by the surgeon and PA.
Upon completion of the bypass portion of the procedure, the pump is removed and the heart is warmed. At this point, if everything is going as planned, the chest can be closed with wires and the surgery is complete. Depending on the surgeon, number of bypasses, and other factors, the duration of the surgery varies greatly; however, typically it will be at least 3-4 hours.
This Site Was Unique
The PAs at this site were allowed to do so many more things than I have seen other PAs do in any other specialty. It was clear that this was still not even the norm for this specialty as most of these PAs have worked in this field for a long portion of their career. The three surgeons in the group were very trusting of the PAs that they have worked with for over a decade, allowing them to attach the proximals, attach the cannulation, and much more. The PAs at this site were thrilled to learn and do more every day, to them this was more than exciting, they could not get enough of procedures and took every opportunity to learn/try new things, and perfect their skills. What made me so impressed was that they were not "one trick ponies" they worked and managed their patients on the floor and knew medicine just as well as they knew surgery. Every one of them was highly admirable, they are intelligent, skilled, and still very grounded as people. I highly look up to them and hope to experience something as great as them one day. They truly have reached the ceiling of the PA profession as they are not just surgeons, they are amazing clinicians.
I cannot begin to explain how excited I am for this rotation. The balance between critical care management and surgical procedures makes me happy on so many levels. Most of the days during rotation we round on all of our ICU patients and some of our floor patients, have 1-2 cases, then either return to the floor for some more consults or discuss some topics and call it a day. The CTS PAs and surgeons that I am working with, currently, are some of the most down-to-earth, extremely intelligent people I have been with so far on rotations. Everyday is almost always full of laughter and learning from one another. It still boggles my mind the amount of hours they all put in during their schedules--they can work close to 80 hours a week. Often, the PAs are on call (24hr) every 3rd/4th day, yet they still are friendly and genuinely nice people.
Never in my wildest dreams did I think that I would get to see and do some of the things I get to do on this rotation. On my first day with them, I was able to intubate a patient and first assist during the majority of a coronary artery bypass. By the end of the first week, one of the PA's was letting me try my hand at harvesting the graft! Most surgical things have seemed to come quickly to me, harvesting is a little tricky to learn as time is a factor to have the graft harvested and prepped by the time the surgeon is ready for it, (which limits some teaching moments). Nevertheless, the two times I have been able to try my hand at it, I have already seen much improvement since the first day I touched the scope. Fortunately, I have been with this team already for two weeks back in my general surgery rotation which allowed me to jump right in where I left off. They let me close the small leg wound by myself and let me help close the chest at the end of the case. One of the surgeons even let me sew on the heart! My little prolene knot is in a patients heart right now! How cool is that?! (its the small things that bring the biggest joy).
Not only have I grown by finally finding the right types of gloves that work best for me (thanks to the scrub tech, Billy), or what shoes are most comfortable during longer cases, but I have genuinely noted some personal growth in many of the surgical procedures. Originally, closing the wound was a daunting task, but now I look forward to it at the end of the case because each time, my closures are looking better and better (and I'm getting a tiny bit faster too).
Some small take-home points from the first few weeks:
The Power of Observation:
IN THE OR: For once my overly observant nature is actually very useful. Instead of noting what color shoes or tie someone is wearing, I turned my attention to survey the surgical field. When the surgeon is focused on sewing the graft, his suture could easily get caught on any of the nearby equipment (that he cannot see because of his magnifying loops he has on), it is our job to make sure it doesn't. Think about how small some of these vessels are, the simplest tug can tear it at any point. Basically, if something doesn't look right, speak up, ask questions when needed because it is for the patient's safety and well-being the majority of the time.
FOR ANY PROCEDURE: In addition to assisting, when learning how to perform any procedures, it is worth while to pay extremely close attention when shown how to do something the first time. For example, if learning how to place a chest tube, don't just watch the tube and where its being placed; note the specific way they find the rib, the way to make the incision, how they open the incision, the way they hold instruments, and how much pressure at which they have to push to advance the tube in. All of these things are small in comparison to the steps noted in "how to perform" procedures; however, they allow you to be fully focused, engaged, and observant which will create a better foundation for the memory on performing these procedures again on your own. I find that the most I can observe from the first time I watch a procedure to the first time I attempt it on my own, the better my attempt will be and the fewer questions I will need to ask. After all, our goal is to be proficient in whatever we practice.
The surgeons each have a slightly different way of performing the same procedure. That being said, as the PAs we need to know each of the different ways they liked everything done. Essentially, its a game of chess, where we need to be a step and a half ahead of the surgeon to know what they want to do next, what can go wrong, and what we need to do if it does. The same PA who taught me this also said that we "need to be one step behind as well" to fully grasp everything going on in the field and allow for the smoothest operation. After being with these surgeons for a few weeks now, I am starting to remember the little differences between surgeons already.
Being Meticulous is Often a Good Thing:
Often, I have been told that I am too focused on the details; well, in this area when we are working in milimeters, precision is key and worth the time. Often, I ask my preceptors what they think of the wounds I have closed, the drains I have secured, even they proper way to hold and cut left handed with scissors because habits can form form the first few times you practice something. I would rather learn and train the right way than have to fix bad habits later. In the end, the extra time taken to make sure everything is done correctly, will benefit the patient in the long run, and prevent complications.
I am pleased to say that I loved this rotation and am very sad that it has come to an end. The end of this rotation has already had a bitter sweet moment for me as my preceptor left for vacation before my last week. As we were in the middle of our last ACL reconstruction together, our last rotator cuff repair, and even just last knee arthoscopy, I felt a genuine saddness realizing that I may never work with him again--I realized that although unanticipated, I really enjoyed orthopedics, especially with him and his PA.
The last week I was able to do some different things in orthopedics including work with his PA one-on-one. She was very much "to the point" but an extremely intelligent preceptor. As my friend said, who had her for this rotation as well, "she is only making me a better PA." I could not agree with her more! There are times when preceptors would be tough for no reason, (or even mean for no reason), but then there are preceptors like this orthopedic PA, who is one of the best preceptors I have had because of her ability to bring out the best in us as students. Most of the time I feel pressured and stressed because she asks tough questions that we SHOULD know the answers to--and she knows that. All in all, in a strange way, I look up to her because of the way she explains procedures to the patients, validates their concerns, but remains efficient and productive at the same time.
During the last week, I spent two days with another orthopedic PA who works with doctors who specialize in hands (and other upper extremities). This was a different experience that allowed me to see all new types of conditions, injuries, and follow-up's from surgeries. The PA was a fantastic teacher, she spent extra time with me to explain new concepts and conditions. There were so many conditions I have never even heard of before! I guess when you are working with a specialist, you see all the zebras! She as well as the other providers helped grow my fascination in orthopedics.
One of my most recent cases was a patient with a tri-malleolar fracture due a slip on ice. Due to this time of the year, in the lovely northeast, I would like to go over some details about how a simple slip on ice can lead to an injury that requires surgical intervention.
Below are photos up that I drew just for some basic anatomy of the foot and leg.
Lets say a 54 year old female presents to your urgent care with some ankle pain after her fall on the ice. She is wheeled into the clinic as she states that she cannot walk on her foot. After getting details of her fall and note that she cannot bear weight on it since the fall, you start your physical exam. You inspect her ankle and note significant ecchymosis (bruising), maybe even some around her calcaneus. She has limited ROM due to pain with flexion and extension of her ankle and is extremely tender to touch on both medial and lateral malleoli. She is not tender on the dorsum, metatarsals, or navicular region of her foot.
Before getting x-rays remember the OTTAWA Ankle Rules to determine if x-rays are needed:
Weber Ankle Fracture
This fracture has different classifications depending on how many ligaments are involved. A Mortise view of the ankle is best used for diagnosis along with clinical examination.
Weber A *Every ligament is intact with a fibular fracture*
Tibiofibular syndesmosis is intact (attachments of distal fibula to distal tibia).
Deltoid ligament intact (attaches medial malleolus to the calcaneus, talus, and navicular bones)
Fracture of fibula below Mortise (talotibial joint line)
Typically stable and does not require surgery
Weber B *Fracture of fibula is at the same level of Mortise*
Tibiofibular syndesmosis is intact maybe a mild tear
Deltoid ligament intact or maybe torn
Fracture of fibula at the same level of Mortise
Can be stable or unstable (if unstable requires ORIF)
Weber C *Widened talofibular joint with fx above Mortise*
Tibiofibular syndesmosis is torn causing widened talofibular joint
Deltoid ligament torn ± medial malleolus fracture
Fracture of fibula above Mortise
Unstable and requires ORIF
Photo from an awesome slideshow on Slide Share http://www.slideshare.net/drhawler1/ankle-injury-amanj
Common Ankle Sprains
Note that regardless of the type of Weber, the Anterior Talofibular Ligament is intact, this is the ligament that attaches the lateral malleolus to the talus. ATFL is most commonly torn/sprained with ankle inversion injuries (think of twisting your ankle with the sole of your foot turning inward). Other ligaments in the lateral ankle complex are the calcaneofibular ligament and posterior talofibular ligament.
If you were to sprain your ankle with an eversion injury (turning the sole of your foot outward), this would likely injure the deltoid ligament which, as stated above, attaches the medial malleolus to the medial foot). There are 4 ligaments that make up the deltoid ligament (posterior tibiotalar, anterior tibiotalar, tibiocalcaneal, and tibionavicular) the names are easy to remember if you remember where the the ligaments are attaching.
Grades of Ankle Sprains
I. Ligament stretched but intact (able to bear weight, and do normal activities)
II. Partial ligament tear (difficult to bear weight, able to do activities but with extreme pain)
III. Complete tear/rupture of the ligament (unable to bear weight)
I could not be luckier to have had general surgery prior to orthopedics! There are so many powertools and equipment in ortho that could seem extremely overwhelming if I stepped into this before general surgery. Some of the tools are familiar like basic suction, Bovie cautery, and retractors. Even with basic knowledge of the OR, I still find myself slightly overwhelmed by all the different tools being used. Usually, the PA's aren't the ones using those tools but it is still important for me to know about them and how they work.
Similar to Cardiothoracic surgery where the PA harvests the vein from the leg, the PA is responsible for cleaning up the hamstrings/tendons for ACL reconstructions. Unlike CTS, the PA is not the one harvesting the tendon, but they do have their own side project cleaning it up and stripping the muscle from it.
Typical ACL reconstruction is pretty cool! First the doc marks out where he wants his incisions to be (like any other surgery), then he finds the sartorious fascia where he makes an incision. There are three different hamstrings in the leg: Semitendinosus (Semi-T), Semimembranosus, and biceps femoris. With my doc, two inferior tendons are taken for the reconstruction: the Semi-T and the gracilis which is right next to the Semi-T. The tendon hook shown in the first image is used to isolate the tendon from the leg and release it. Once the tendons are removed, they are stripped of their muscle and whip stitched to allow for manipulation and placement in the joint. In the photo on the right, a boneplug is placed to anchor the tendon into the bone. This is done on each end of the tendon to help secure the newly constructed ACL. The doc then does a manipulation of the joint to make sure it is stable and everything is working appropriately. At flexion of the knee the ACL should have some laxity to it, which is examined for at this time. This part of surgery seems to be unique to Ortho. Manipulation is also parts of other surgeries including some shoulder surgeries.
The patients will take a couple months to get back to walking normally and up to 6 months to start getting back to full exercises. They are sent home on a knee immobilizer and will start progressing slowly through regular visits to ortho and Physical Therapy.
My rotation involves only two days in the OR each week and three in the various clinics that my doctor goes to. The variation makes the time go by pretty fast! However, he sees close to 60 patients a day (if not more), which makes the pace of learning even faster! "Taking the training wheels off" as he said, he started letting me see patients on the first Friday of the rotation. Surprisingly, I picked up the examination for shoulders and knees pretty quickly. Ortho has always been a weak point for me as it involves a lot of memorization! That being said, I am working extra hard this rotation to keep up with his busy schedule.
I think that Ortho involves a lot of anatomy that bases the diagnosis and treatments unlike other specialties that involves more physiology. I find myself studying detailed images of joints daily and attempting to perfect my physical examination of shoulder and knee exams.
Images from google search website: http://www.staehelin.ch/st/figvrze.html#graft-harv
After spending a few weeks with the general surgery team, I started to get a good grip about what the field was about. Everyday you can almost guarantee that you have a laparoscopic cholecystectomy, some variation of a hernia repair, and maybe a diagnostic laparoscopy. However, sometimes we get some interesting cases.
There was one patient who recently had a colonoscopy then was discharged home to find that he/she started having some abdominal pain. Later that day, through the ER, the patient arrived back in the OR for a ruptured spleen! There was a capsular tear (grade II splenic injury), and due to the amount of bleeding the spleen was removed and bleeding was controlled with sutures. Thanks to skilled surgeons, the patient did well in surgery and went stable to the PACU.
A unique role as a PA in general surgery is that there are many different surgeons, who all like to do things differently-- from suturing to cleaning the camera lens, each surgeon differs. As a PA, you not only have to know what is going on in the surgery but also be a step and a half ahead. This is what makes a good surgical PA, perceptiveness and attentiveness. Obviously, being proficient in suturing, laparoscopic skills, and other OR skills is a necessity, but mentally, you have to be prepared as well.
The surgery team I worked with was very nice, after demonstrating some skills, they allowed me to suture more port sites, wounds and other tasks as the rotation continues. Each surgeon is different but most allow PA's to close the wounds after the majority of the surgery is over.
I look forward to my last week here because I feel like I cannot get enough of my time in the OR. (Then again, my next rotation is Ortho, where we will be spending lots of time in the OR.)
On a side note:
Fortunately, I met a perfusionist in the hallway who introduced me to the cardiothoracic team during my time in general surgery as all the OR's are right next to one another. Nervous and intimidated I walked into the OR where they were closing up the chest. I almost thought I was "sneaking out" in a way, like a little kid stealing candy (but general surgery didn't care). Unbeknownst to me, they were some of the friendliest people I ever met!... so much so that they even took me on their team for a few days! Some of my best days were spent with this team as they were eager to teach and let me practice new skills. By the end of my time with them I was intubating patients in the OR and the floor, placing drains in OR, removing them on the floors, suturing all sorts of things and loving every minute of it! The surgeries were long, but they felt so short! The time just flew by! Before I knew it were were taking the patient off the pump and closing the chest. The PA's were even closing the large wounds once the surgery was over, they have such autonomy here. A nice twist to their team was that the PA's did not only reside in the OR, but also managed the patients themselves while they were in the ICU/CCU. The PA's were a vital part of the CTS team and I couldn't help but idolize them. They had a higher level of responsibility than PA's on any other rotation I had been on-- I was envious. This is what I dreamed of, this is what I always wanted when I decided to go to PA school, this is who I want to be. Thankfully, they were friendly enough to invite me to stay for an elective with them. I cannot wait to learn more skills with them at my side. It feels so surreal, but this is it, this is where I will find out, might I actually become a cardiothoracic PA?
First of all, I would like to apologize in the delay of getting these upcoming posts up and published. During our clinical year we have a two week vacation between Rotation 8 and 9 to help us spend some free time with our families during the holidays. But now, back to the books... and hospitals...
Now to wrap up my internal medicine rotation I would like to mention a few things. At first, I was probably most nervous starting this rotation but felt most at home by the end. This rotation was at our local medical college hospital, meaning that the medical students would also be on our service working with the patints as well. I was fearful that the med students would know more than me, be able to do more than me, answer questions better than me etc. I will not go as far as to say that I was wrong in that regard, but we simply had different skills and strengths. I was familiar with many common treatment regimens and modalities that they have not necessarily learned yet, and they were better versed in conditions at a cellular level (being able to explain details of processes and pathophysiology). Many procedures I had done previously that they had not had the chance to do, which was surprising to me. Aside from knowledge, I was fearful that they would not be accepting of me (as I fear with joining any already-formed groups). Now here is where I can say that I was completely wrong; the med students I worked with were exceptionally friendly and included me in all of their extra lectures and events. By the end, I felt like I was genuinely going to miss them--and I do!
A few positives about the field of internal med:
1. You take time to get to the deeper issue.
I loved this aspect of IM. We could spend two hours rounding on our patients just discussing cases, lab results, interpreting imaging studies and determining treatment regimens. At first I thought that I would not be patient enough for this type of thinking process, but as it turned out, I loved MEDICINE. I loved the process, the research to learn more about patient conditions, new treatments, etc. I was pleasantly surprised that this was the aspect I loved the most.
2. You may have patients for a few days, or maybe only one day.
There is a nice variety that comes with IM. Some patients come and go while others spend days with a complicated condition. This allows you to get to know your patients a little better. Everyday, we walked into their rooms and built a rapport with them.
3. You are working with a network of people.
From nurses, to social workers, to techs and other docs/PA's, there are so many people around to offer advice and discuss cases amongst. I felt that when used properly, the network of people surrounding the medicine team is extremely beneficial. Afterall, you don't have to do EVERYTHING by yourself.
Now many of these points are also true to other fields of medicine as well such as family practice and even pediatrics to a degree. But this rotation made me thing differently about medicine...After this rotation, I am realizing now more than ever, that I really enjoy the "thought process" of disease/condition.
Unlike most of my other rotations, this rotation allows a lot of autonomy without responsibility. As students, we get a comprehensive history and physical on the new admissions and present them to the residents and attending. The residents and attending have to see the patient as well, so there is a lot of overlap to make sure we aren't missing information from the patients. Unfortunately, the patients often get frustrated with the repetition of questions but it is a teaching institution and at least we are being thorough. Overall, the team/floor I am assigned to for this rotation is very comfortable and relaxed which creates for a great learning environment. Some of the residents, as well as the attending, will switch 2 weeks into our rotation, so hopefully the new group of physicians is just as friendly as this group.
Some common cases we have seen in Intenal Medicine:
ACS rule out
So far, our attending has been extremely helpful and willing to teach us many different topics including metabolic acidosis. Now, in PA school, we learned the basics about how to tell if acidosis is respiratory or metabolic. We briefly talked about how to tell if there is compensation; however, we did not learn more details about types of compensation, anion gap, or if the problem is acute or chronic.
Thankfully, this attending was very patient and presented many different problems we could work through to practice calculations and cases. It was interesting to see that the residents, medical students and myself, the PA student, were all really benefiting from this review. This is just one example of his teaching sessions with us, we have also discussed, cirrhosis, hyponatremia, and DKA so far. I am extremely grateful for this experience, because without these teaching sessions, I would not even have a grasp on this material like I do now.
Daily Routine on IM:
In addition to my team's attending, there is another attending who lectures to us on a daily basis (each morning). Medical students present a patient case to him and he works through the thought process about how to approach the work-up and treatment of the patient. His approach to medicine is very logical, group things together, each diagnosis is coupled with certain presentations. Instead of looking at problems individually, we should be looking at them through pattern recognition. Over time, this way of thinking makes approach to various cases much easier and faster.
After these amazing lectures which are both informational and humorous, we each round on our patients on our own, then round/present together with the attending. See outline of daily schedule below for our team in particular. For the most part, this rotation seems relatively organized from a learning perspective and it is very helpful for building and solidifying our medical knowledge.
Example of a Day on IM:
6:30am: arrive to follow-up on previous patients, look at any new labs, imaging, consults or other reports
7:15am: varying by day, all the medical students (and PA students) typically have a lecture at this time by the Chair of Medicine attending (who is also an infectious disease doc)
8:30am: return to floor to finish rounding on patients, gather more information as needed
9:00/9:30am: start rounding on patients with attending, present new patients or any updates on patients, typically we have been finishing around 11:30/11:45
12n: depending on the day, a conference or just lunch time
1:00pm: Wednesday's there is "junior rounds" where another attending from a floor comes to discuss a case and the thought process for approach to work-up, management and treatment.
Anytime in the afternoon: Our current attending and residents run a "teaching session" where we discuss various topics related to our patients. For example, I presented on hyponatremia yesterday because we have had multiple patients with various presentations of hypoNa+.
After the teaching sessions, we can stay if there are new admissions to the floor, if not, we are typically dismissed.
**As many of you can tell, I graduated AMC's program in May of 2017. Current plan is to start a new blog related to my Fellowship after PA school. Stay tuned for the link and updates :)**