Monthly Archives: May 2016

Tearing off Training Wheels

PA school is super stressful and overwhelming.  Graduating and starting your first job and your first year out in the real medical word is equally stressful; but, in different ways.  I started my first job and felt like I had no idea what I was doing and like I hadn’t even prepared in the least to walk around a hospital.   Not because I didn’t get a good education at Pitt.

I believe there are several factors as to why I felt like I was attempting to ride a uni-cycle at first.  First, just as elementary and secondary schools are pushed toward performing for a test–so are PA students.  We spend 2 years obsessing about passing the PANCE and all of the horrific things that can happen if we fail.

Second, the PA profession was derived around filling the shortage of Family Physicians.  Thus the education model we follow although follows a general medical concept has a strong focus on family medicine. As I have talked to students who have gone through the same program as me I hear that they are adapting and learning different information and procedures to adapt to the ever diversifying role PA’s are filling.

Third, PA school is FAST.  There is only so much time to learn a lot of information.  I look at the doctors I work with or PA’s with  couple years more experience than me and I think damn “when will that be instinctive for me?”  I quickly decided I would treat my first couple of years in medicine as a resident would.   I do a lot of reading and ask A LOT of questions.

The next reasons are a bit more unique to me; but, perhaps others have experienced them as well.  Before PA school I did not obtain my HCE in a hospital or medical setting.  Even though I had a couple of rotations in hospitals they were pretty sub par despite my constant asking to learn ad do new things my preceptors weren’t particularly helpful in these settings.  So, when I started work I felt like I was still acclimating to a lot of things.  The job I took was also pretty low acuity patients with repetitive problems. The group I was with was great; but, once I got out doing hospitalist work I was like “holy shit”.  I worked basically taking care of post operative patients medical needs.  It got really repetitive pretty quick–every once in a while we had a unique case.  Usually it was standard post operative stuff surgeons didn’t want to handle.

So, when I started my position as a travel PA as a hospitalist at the largest medical resource between Pittsburgh and Philidelphia I felt really intimidated.  I remember my first night getting my first page I had to go and assess a patient.  I felt like I forgot to do a H&P and how to critical think.  it was a really weird feeling that I  can’t quite explain.  I look back at that day and I laugh to myself.  I’ve come a long way since then.  Practicing more independently and handling floor patients in the middle of the night pretty much independently (unless you have to push adenosine–then you call your Attending because–well that was above my pay grade to do that alone the first time on a patient who was a no code).  I’ve become more comfortable responding to RRT’s, even getting a system down as to what I would do to assess the patient and what questions I would ask the nurses.

I still feel like I’m losing my balance some days.  I partially think that is the nature of medicine and also being a PA–we’re expected to know about a lot of things in a short amount of time.  However, I think back a lot to my first day of PA school and my first clinical semester and first rotation, etc.  I realize I’ve come really far.  Even if some days I feel like I know nothing when it comes to a really complicated patient.  Then I remind myself that I would rather feel stupid temporarily and learn as opposed to feeling like I know everything all of the time.  First because that is dangerous and second that would mean I’m not being challenged.

The past can be evil, but it can also be our friend.  Make sure to realize how far you’ve come and everything you’ve learned!  Feel lost, ask questions and take things on before you think you are ready.  You will be ok and your medical knowledge and skills will advance. I sure as shit had never heard the term protein losing enteropathy before and I remember feeling super intimidated by trying to figure out how the hell to order sliding scale insulin.  I still don’t know much about protein losing enteropathies; but, I’m pretty sure I’ve gotten insulin and a lot of other things down since I was cut lose a year ago.  Always remember progress is always being made!!

 

Medical Musing of the Week: Behcet Disease

Overview

  • Disease marked by recurrent eye and genital lesions as well as ocular involvement.  Autoimmune/autoinflammatory disease with a hereditary component.

Etiology/Pathogenesis

  • Perivasculitis and early neutrophil infiltration w/ endothelial swelling
  • Association with HLA-B*51
  • Mediterranean descent/region, middle east and far east

Clinical Manifestations

  • Recurrent oral and genital ulcers
    • Painful with yellow necrotic base
    • Can occur alone or in clusters
    • Subside in 1-2 weeks w/o scarring
  • Integumentary Involvement
    • 80% of patients also have skin lesions
    • Folliculitis, Erythema Nodosum, Vasculitis (infrequent), sweet syndrome and pyoderma gangrenosum
  • Ocular Involvement
    • 50% of patients experience ocular symptoms
    • iritis, uveitis, retinal vain occlusions, optic neuritis
  • MSK
    • 50% have arthritis or arthralgia
    • Knees and ankles most common locations
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                                               Clinical Manifestations of Behcet’s Disease

Diagnosis

  • Clinical
  • Pathergy Test
    • Introducing a needle under the skin resulting in an abnormal healing and development of ulcers and raised erythematous area demonstrating irregular healing
Positive Pathergy Test.  Increase in inflammation and erythema represents impaired healing
Positive Pathergy Test. Increase in inflammation and erythema represents impaired healing

Treatment

  • Methylprednisilone 
    • 1 g administered intravenously for one to five days,  for progressive, severe, organ or life-threatening disease.
  • Colchicine
    • Effective for mucocutaneous involvement
    • Also associated with decrease in joint involvement for men and women and genital lesions and erythema nodosum in women
  • Azathioprine
    • Patients treatment with steroids and AZA demonstrated less vision deficits and blindness
  • Cyclophosphamide
    • 1 to 2.5 mg/kg per day, orally
    • 1 g or 0.75 to 1 g/m2 by monthly infusion IV
    • Effective for neurologic and vasculitis associated with Behcet’s

Complications

  • 30% develop DVT and PE is a rare complications
  • Blindness may ensue from Panuvitis
  • CNS Behcets: IL-6 is persistently raised in cerebrospinal fluid of these patients

 

 

 

 

My Journey

I’ve gotten a lot of questions recently about what my journey was like up until the point of getting my acceptance letter to PA school.  I also realized that I ask my clients (and patients) a lot of probing questions and there are a lot of things they don’t know about me!  Not because I’m unwilling to share; but, mostly because I focus on other people in my work.  Ok, enough chit-chat I’ll get down to it.

A brief background: I was pretty aimless academically in high school.  I was not your traditional straight A valedictorian type.  I worked hard and did above average; but, I don’t think anyone ever saw me as “smart”.  My mind had other areas of foci.  Mostly I was always an athlete first.  My mom was super sick with cancer most of my childhood and I think it probably took more of my mind then I realized or would ever be willing to admit.  I based college on where I would play softball and had no idea what in the hell I was doing when I went to college.  All I knew was that I was getting away from home and that made me happy.  Also that going to college was what everyone was supposed to do, so I did it.

If I had to do it over again, everything would be different.  Maybe not high school, but college for sure.  I would go to community college get whatever credits I could as cheap as possible.  I would have vacated the mid-west ASAP. I wouldn’t have majored in psychology and I wouldn’t have gotten a master’s degree around the same concentration.  WHAT WAS I THINKING. I was pretty hopeless and I think I suffered anywhere from a 4-7 year quarter life crisis. 

So, there I go proceeding with about 120k in student debt and a lot of people in my life cocking their heads at me wondering what the hell I was doing.  I didn’t know what the hell I was doing for the record. I was 24 years old working as a personal trainer and bartender.  I knew about half way through my Master’s it wasn’t right for me, but decided to finish. What the hell was I doing?

When I was working as a personal trainer a worked with a lot of medical professionals.  I talked to them a lot about what kind of work they did.  It interested me, medicine always interested me. As cliche as it sounds I was obsessed with all the typical medical shows–ER and Grey’s Anatomy (by the way as truthful as it is don’t put this in your personal statement 🙂 One day, a friend of mine who I was training brought in a brochure about Chatham’s Physician Assistant program.  I was like this is it.  I want to do this.  I sat down made a list of all the crap you guys know needs done to have a complete PA application, made a time line and never looked back.

I decided to stay in Pittsburgh if I could to avoid out of state tuition. Yea, I know good time to start worrying about that.  I also wasn’t interested in up rooting my life at this point.  So, I compiled a list of 5 schools wrote down all the classes, GRE, supplemental apps, letters of rec, etc that I needed–sent in my application to CASPA beginning of June, visited all the programs I was applying to, got an interview at Pitt, got accepted and the rest is history.

I realized not a lot of people agreed with my choice.  Of course no one vocalized anything. But you can always tell when people think you’re bat shit crazy. People did.  I didn’t particularly care.  As for why I didn’t really have much academic confidence when I was younger I’m not really sure.  The older I got and the more purpose I had in the science courses I was taking the better my performance became.

If you have a purpose you have a path.  Don’t let barriers stop you or others disapproval–or seeming disapproval.  Just bite the bullet and jump. I had a lot of reasons why I might not get an interview or get accepted.  I’ve also talked to a lot of people who focus on this detail.  Don’t let the don’ts come into your house and set up camp in your brain.  Don’t go down the don’t rabbit hole.  Remember you are unique and if you’re reading this you probably have your shit enough together to see how other people did it and that makes you a step ahead of a lot of people.  Always give yourself credit.  Smile. Be confident.  I’m convinced anything can be accomplished with these simple statements.  Good luck everyone!!  

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