Week 13: A Little Taste Of Freedom

          Thanksgiving break came just at the right time! It has been amazing having some time to relax the past couple of days. Although the workload and my study schedules have not completely vanished, it felt great taking some time off to enjoy family (cook and eat too!), especially yesterday. I returned to my normal study regimen today (kind of), and my head will definitely be back in the books tomorrow.

          This school week was a short one; I only had classes on Monday and Tuesday. In ID, we focused on fungal infections (candidiasis, histoplasmosis…etc.) and in Anatomy, we continued to dissect Summer. This week we dissected Summer’s neck to uncover more muscles, vessels, and nerves in the area. Next week, we complete the semester-long dissection by excising the skin on Summer’s face, to uncover her facial muscles. For the past 13 weeks, we have had the faces of all of our cadavers covered with a towel, so I barely remember what Summer (or any cadaver) actually looks like. The unmasking should be interesting…

          I also mentioned last week that our final Behavioral Medicine lecture would entail all 54 of us students participating in an ethical scenario. The ethical scenario is actually based on a true malpractice case. The case involves a woman who is diagnosed with breast cancer, and based on the nature of her diagnosis, opts to undergo surgical removal of both of her breasts. Following surgery, as recommended by her oncologist, the same woman undergoes aggressive radiation therapy, and later survives a near death experience in the ICU (resulting from a complication of several combined post-surgical therapies). Long story short, from the beginning of her breast exam/biopsy, her name (and therefore chart and breast biopsy results) was switched with that of another patient. So, the woman who underwent the double mastectomy (removal of both breasts), and aggressive post-surgical therapy, did so for absolutely nothing…she never actually had the invasive breast cancer that she was mistakenly diagnosed with. This woman was counseled and treated by many healthcare professionals throughout the course of this specific malpractice case, and so there are many people to blame for such an occurrence. On Tuesday, each of us 54 students will play the role of one of the healthcare professionals that this patient encountered throughout the course of her faulty diagnosis and unnecessary treatment. It will be our job to diffuse the issue, if that is at all possible. I wonder what healthcare professional role I will play (I don’t find out until Monday night)…

          Only one more week of classes remain before finals begin. I hope to get as caught up, again, as possible by the end of this weekend, before I’m loaded up one last time with new information in this coming week. I can sense that my eat, sleep, study regimen is just around the corner…

This week’s question: True or false: The number of bones in the human wrist is equal to the number of bones in the human ankle.

Last week’s answer: A BRAT diet consists of bananas, rice, applesauce, and toast. 

Week 12: Catching Up

          Four days ago, I finally felt as though I was ‘caught up’ with the material for most of my classes…today…not so much. I am starting to think that it is impossible to ever be all caught up in PA school. This week was one of the most overwhelming weeks of the semester, by far. We spent a couple of weeks dissecting Summer’s legs in lab, and I struggled to learn all of the structures (muscles, vessels, nerves…etc) in two weeks time. This week, we dissected Summer’s arms, and there is just as much information (if not more) to learn for the arms as there was to learn for the legs. I have just this weekend to master this new information, and next week we begin dissecting her neck (more new information!). Something tells me I will be living in the cadaver lab leading up to finals (in four weeks). I would love to spend all of my time studying anatomy, but with six other courses to keep up with, it’s just not an option. I remember complaining in undergrad about having only a month to learn half of the amount of the information I’m learning now…

          This week in Behavioral Medicine we discussed, as a class, the details of our standardized patient lab interactions (from last Friday), and then proceeded to discuss how to best break difficult news to parents about the health of their child/children. In a practice scenario, the class was portioned into groups of three. Two of us in each group were a married couple, and the other member of the group was the PA. We (I was the father of the couple) presented to the PA with our 18-month-old child who had been exhibiting signs of weakness (poor muscular strength) for some time after birth. The PA had to inform us (the parents) that our child tested positive for spinal muscular atrophy (SMA), a genetic disorder with a fatal prognosis. The disorder would progressively weaken the muscles of our child, ultimately culminating in respiratory failure by two years of age. As is apparent, these scenarios are not getting any easier! Luckily, I was able to take a break from breaking the bad news, and rather be the one responding to the bad news (though it’s such awful news to receive). We have one more Behavioral Medicine lecture (after Thanksgiving break), which will entail all 54 of us students participating in a final ethical scenario. I’ll fill you in a bit on that scenario next week.

          My other classes (GI, ID, Physiology, and PA Professional Issues) have been manageable. PA Professional Issues actually ended today, so I no longer have Friday classes. The past couple of weeks in GI have focused on infections of the GI tract, especially those that cause diarrhea (so, a lot of poop talk the past couple of weeks). We also learned about vitamin deficiencies and other malabsorption disorders (Celiac disease, lactose intolerance…etc). This week in GI, we focused on disorders that affect the colon and some areas of the small intestine (Crohn’s disease, ulcerative colitis, irritable bowel syndrome). In ID we have begun focusing on viral infections (mononuclueosis, herpes, HPV…etc). Both of these courses end in three weeks. I will take the finals for these courses one week before all of my other finals, which will spread the exams out a bit.

          Although I’m a bit overwhelmed at the moment, I am so close to the end of the semester, and this is what is keeping me motivated to try my best to keep up with all of the new material. It will be another long weekend, no doubt. Thanksgiving break could not have come at a better time…I need a mental break as soon as possible!

Question of the week: You are steadily recovering from a course of diarrhea, during which your PA recommended that you remain on a BRAT diet. While on this plain, limited diet, what food items have you been consuming? (Hint: Each letter of the acronym BRAT stands for one of the four food items)  

Last week’s answer: Together, the five fingers of your right hand contain 14 of the 206 bones of the human body. The thumb contains 2 bones (called phalanges), and the other four fingers each contain 3 phalanges (accounting for 12 more phalanges), for a total of 14 finger bones.              

Week 11: Life And Death

          Well that was an experience I’ll never forget…let me fill you in on the events of my second standardized patient lab (again, the ‘patient’ I will speak of is a paid actress, hired by my PA program to act as a patient).

          I arrived at the standardized patient lab, with eleven other students, ten minutes before my scheduled appointment at 9:00 am. Each of us was instructed to stand outside of one examination room, and review the medical history chart of our patients-to-be. As indicated by the information on the patient’s chart, he or she presented one week prior with persistent headaches, and, as a result, the patient was prescribed a head CT scan to rule out any unusual causes for the headaches. At this follow-up, 25-minute appointment, it would be our task to discuss the results of the CT scan with each of our patients. At 9:00 am, we were all instructed to knock on the doors of our respective examination rooms and meet our patients. So, I knocked three times and entered the room…

          When I entered the examination room, my patient, a middle-aged female, was pacing and breathing fairly quickly and heavily. I introduced myself as the PA, and she instantaneously expressed how nervous she was about receiving her CT scan results, so I calmly (as possible) told her to have a seat. After washing my hands, I sat across from the anxious patient, who told me that she was in a rush to get back to work and did not have much time to spare. I then looked her straight in the eyes (my heart dropping to the floor at this point) and informed her that the results of her CT scan were consistent with a Stage IV (highly invasive and aggressive) brain tumor…

          Gliobastoma multiforme is a highly malignant (Stage IV) brain tumor that is fatal in nearly all patients. Sources vary on the exact nature of the diagnosis, but symptoms are typically consistent with headache, nausea and vomiting, and focal deficits (symptoms that vary depending on the location of the tumor in the brain). The causes of such tumors are currently unknown, and the prognosis (outcome) for each individual varies. Generally, sources document that, without treatment, patients live no more than six months, with aggressive treatment (surgery, radiation, and/or chemotherapy), patients may live up to fifteen months, but very few patients live past two years upon the onset of their symptoms. Often, surgical removal of the tumor cannot guarantee total removal of all of the cancer cells. The tumor literally resembles an octopus, with a central core that spreads tentacle-like projections to other surrounding areas of the brain (this is what makes total removal of the tumor nearly impossible). And I, a 2.5-month-old PA student, had to break this news to my already distraught patient…

          After breaking the news to my patient, she sat silent, in awe, stunned by the results. She was shocked that her diagnosis was so serious after presenting merely one week ago with such mild preceding symptoms (her headaches), and was certain that the lab technician had mistakenly switched her scan with that of another patient. As uncomfortable as it was, I opened her chart, and reviewed the CT scans with her, showing her the location of the tumor and explaining the reasons for her associated symptoms. I would say about five minutes were spent explaining the nature of the tumor; the other twenty minutes were spent consoling the patient. She was very concerned about her husband and children, overwhelmed by the mortality rate of the condition, and unsure of the next steps to take. As I addressed each issue with her, she would occasionally drop her head down and start crying, but I was sure to stop talking at these sensitive moments and rather take time to console her. The point I stressed most was that she would not be alone when making all of the many difficult decisions; rather, she would have the undying support of her loved ones, and, equally important, myself. I wanted to ensure that she left the appointment with a bit of hope that her treatment course may vary from that of the general population. She seemed to understand that the condition was fatal, and she even asked me if she was going to die. I cringed inside when she asked that question, but again stressed that although the diagnosis is generally a fatal one, every patient is different and will therefore experience a unique course. When the appointment ended, I was instructed to leave the examination room, and wait outside for my critique…

          About two minutes after the completion of the appointment, my standardized patient called me back into the examination room. Her critique could not have been any more positive. She was impressed with my calmness (bizarre, because I was freaking out before entering the room!), and said that my empathy was clearly and sincerely expressed. She appreciated that I didn’t lose eye contact with her at any point throughout the communication, and that I wasn’t afraid to place my hand on her shoulder to console her (I had to do this about five or six times…I felt so bad for her, even though she was only acting!). So, as nervous as I was, the critique I received could not make me feel any better. This was probably the most intimidating and difficult task I have ever had to complete. Although these situations are not real, the actors and actresses make the simulations feel extremely real (not to mention the cameras in the examination room also watching my every move!). Although I was still nervous approaching this scenario, I did feel more at ease relative to my first standardized patient encounter. Maybe I’m getting used to this…or at least a bit more comfortable. Overall, it was a very tough morning to get through, but now at least I can unwind a bit with some studying. I am so relieved!

Question of the week: Examine the fingers of your right hand. These five fingers, together, contain how many of the 206 recognized bones of the human body?   

Last week’s answer: The largest nerve of the human body is the sciatic nerve.  

Week 10: A Myriad Of Muscles

          It’s hard to believe that I am already ten weeks into PA school…it still feels like I started only a couple of weeks ago. This week (like most other weeks) was jam-packed with new information. In lab, we dissected Summer’s anterior (front) thighs and legs. We had to cut through about two inches of fat tissue before we could uncover Summer’s thigh muscles, but once we did so, we found many (if not all) of the structures that we expected to find. Knowing merely where a muscle is located, unfortunately, is not enough; for each muscle, I must also learn it’s attachment points (to bones), it’s innervations (what nerve supplies the muscle), the muscle’s blood supply (what arteries and veins supply the muscle), and it’s action. With nearly 100 muscles to learn for the final exam (between front and back thighs, legs, arms, and face), I’ll be kept very entertained this month. Also, since each cadaver has two legs and two arms, there will be twenty-four limbs for our professors to choose from for our final…pretty intimidating, but at least I now know what to expect (based on the midterm). The highlight of the dissection was opening Summer’s knee joint. The knee is such a complex joint, so well-protected and reinforced by surrounding ligaments and muscles, and it was an amazing experience to peel away all of these supporting structures to reveal the knee’s inner-workings. Next week we will flip Summer onto her stomach so that we can begin dissecting her posterior (back) thighs and legs, in addition to her hip joints. For now, I have plenty of muscles, nerves, and vessels to catch up on!

          This week in Behavioral Medicine, we received our child abuse recognition certificates (from the class we attended last week). This week’s lecture content focused on various sexual preferences that our patients may present with…well, some of the more atypical sexual preferences. For example, my professor spoke of several items he has extracted from the rectums of emergency room patients, in addition to his treating a female patient with a rare sexual partner…her male dog. Yes, it was an interesting lecture, but as I kept the details of Summer’s pelvic exam to a minimum (last week), I will do the same here! In GI, we learned how to diagnose and treat liver diseases, including hepatitis viruses A-E (there’s even a G!) and various causes of cirrhosis (for example, alcoholic cirrhosis). In ID, we focused on diagnosing and treating sexually transmitted infections (syphilis, gonorrhea, etc…). Up to this point, the Clinical Medicine sub-specialty courses (Dermatology, HEENT, ID, and GI) stress the diagnosis of each condition more so than the treatment. We have been responsible for learning what medications we would prescribe to a patient for each specific diagnosis, but we do not learn how to determine the actual dosage of each medication until we begin our Pharmacology course (we take three semesters of Pharmacology, which begin next semester). 

          Yet again, this was another very productive week. Next week I have to register for my classes for the Spring semester. Registration is less stressful now than it was in undergrad because the program organizes our schedule and classes for us, so we can never be closed out of a class. This semester was a fourteen credit semester, and next semester will be a seventeen credit semester. We have been warned by many that this first semester will be our easiest (that’s comforting to know). Also, next Friday is my second standardized patient lab. We haven’t received much detail on what news we will be breaking to our standardized patients this time around, but I’m nearly certain I will be diagnosing him or her with a terminal illness. So, stay tuned for next week’s post…     

Question of the week: What is the largest nerve of the human body?  

Last week’s answer: A research study conducted between the years of 2007 and 2008 determined the prevalence of child abuse cases (reported and unreported) on Long Island. The presented findings state that, on Long Island, one child is abused every 11 minutes on a daily basis.

Week 9: Accident Prone

          A panicked mother presented to the emergency room with her sixteen-month-old child. Upon physical examination, both of the child’s feet and ankles were reddened and blistered, exhibiting burn marks that extended about two inches above each ankle, abruptly stopping thereafter. The mother, notably upset, reported what had occurred prior to transporting her child to the emergency room. The mother explained that she had exited the bathroom to answer a ringing phone, leaving her child alone, bathing in the bathtub. About ten seconds after her leaving, the mother was suddenly startled by a scream from her child, who had accidentally turned the hot water faucet, which resulted in expulsion of scalding water into the bathtub, the burn marks being the result. The mother’s story, though seemingly convincing, was a blatant lie (as detected by an emergency room PA, my professor). Her child did not stand up in the bathtub and turn the hot water on; it was the mother who filled the tub with the scalding water. It was the mother who then lifted her uncontrollably crying child and lowered the child’s feet and ankles into the water, submerging them long enough to burn and blister. This was the mother’s attempt, her punishment imposed on her child, to stop the child’s persistent crying. This was a prime example of child abuse.

          It is a mandate in the state of New York that PAs become certified in recognizing cases of child abuse and/or neglect. With this certification, PAs are obligated to report suspected cases of abuse to the appropriate authorities. This week in Behavioral Medicine, we acquired such certification and learned how to recognize and detect child abuse, especially based on the faulty stories documented by a child’s abusive parents. The subject was not an easy one to discuss, and the pictures and cases of the abused children that we studied were all extremely disturbing. All of the stories were based on true events experienced (children treated) by my professor, who stressed the importance of recognizing the common excuses that abusive parents may make, like introducing their child as “clumsy” or “accident prone.” We also learned the relative probabilities of injuries that may occur when a child slides down a flight of stairs, rolls off of a bed, or free-falls from various heights. Surprisingly, very minor injuries are a result of such accidents, so if a parent presents a child with broken ribs from a reported “sliding down a flight of stairs,” the parent is likely lying. Overall, I greatly appreciated this lecture, and I should receive my certification, by mail, in the near future.

          In addition to other classes, which I have focused many of my previous posts on, there is another course I am taking called PA Professional Issues. It focuses on all of the legal issues that concern the PA profession, what we can and cannot legally do as PAs, and medical ethics. We have had a couple of group projects assigned throughout the course of the semester, one of which is due next week. Each group was assigned an ethical case to analyze, specifically the legal and ethical issues that apply to the scenario. My group’s scenario goes a bit like this: a middle-aged female who has been our patient for nine years has been battling recurrent cancer (first in her breasts, now spreading to her bones and spine), and she informs us that she doesn’t want to go through “the last of life’s great experiences drugged out of her mind for pain.” She would therefore like our help in assisting her to end her life by discontinuing her cancer treatment. That’s the case that we have one week to solve, so it should make for some interesting class discussions when we present our topic and findings. 

          All of my other classes are progressing well. This week, we dissected Summer’s reproductive system (uterus, ovaries…etc) and learned the reproductive anatomy of the male cadavers as well. Performing my first pelvic exam on a cadaver was an experience I’ll likely never forget (though I’ve been trying my best to forget about it). I’ll keep the other details of the dissection to myself (unless you want the details…in that case you can ask me personally. I’ll tell you all you want to know!). This week in GI we focused on diagnosing and treating disorders of the esophagus and stomach (ulcers, gastric reflux, infections…etc). Our ID class was cancelled this week, so the information will likely be doubled for next week’s lecture. I think this week was one of the more memorable ones. The topics covered in Behavioral Medicine and PA Professional Issues truly verify the fact that this profession does not only entail the physical treatment of patients; there are important emotional and psychological aspects that must be accounted for in the ultimate treatment of our patients as well. As challenging as the schooling is proving to be, after this week, I have never been more certain that I am pursuing the correct career.

Question of the week: A research study conducted between the years of 2007 and 2008 determined the prevalence of child abuse cases (reported and unreported) on Long Island. The presented findings state that, on Long Island, one child is abused every ______________ on a daily basis (choose one of the possible answers listed below).

  1. 37 seconds
  2. 11 minutes
  3. 4.5 hours
  4. 13 hours 

Last week’s answer: The viral infection, associated with fever, sore throat, and swollen cervical (neck) lymph nodes, also referred to as “the kissing disease,” is mononucleosis.