Weeks 59 & 60: Four Down, One Year To Go

It was about two years ago when I first began posting about PA school, so eager to begin the program, excited to learn more about medicine, and share my experiences with others. As evident over my two years of posting, I’ve had many ups and some downs, but I wouldn’t change anything that has happened throughout my schooling thus far. A couple of weeks ago I completed my last five finals of PA school, walked out of the same classroom I entered for the first time not so long ago, and couldn’t feel any better about the change that’s to come in my final year of the program.

I think it’s needless to say at this point, but the final two weeks of the semester were just as chaotic as any other finals week I endured before. Long story short, each final (Emergency Medicine, Clinical Skills, Family Practice, Pathology, and Pediatrics) went well and I never felt more relaxed after completing the seemingly endless two weeks leading up to exams. We finished the semester focusing on HEENT (heads, eyes, ears, nose, throat), Psychiatric, Dermatologic, and allergic emergencies in Emergency Medicine, and in Clinical Skills we practiced suturing skills on chicken thighs and pigs legs (the skin of pigs resembles the texture and tension of human skin). In Family Practice, we learned how to work-up patients who present with complaints of vertigo/dizziness and also how to clear patients for surgical procedures. Pre-operative clearance is much less about simply signing off on and clearing a patient for surgery as the name implies; it has much more to do with ascertaining that the patient is in good enough health and condition to endure the scheduled procedure. Pathology focused on disorders of the nervous and musculoskeletal systems, and Pediatrics focused on the diagnosis and treatment of urinary/kidney, reproductive, muscular, and metabolic disorders. And just like that, in the span of two years, we finally completed the curriculum to be learned prior to our clinical phase year…

So what’s to come over the course of this next year? Let me fill you in…

Less than three days from now, the next phase of my PA program will begin, called the Clinical Phase (rotations). As mentioned before, each rotation spans a period of either four or eight weeks, in which time I will be placed in a variety of settings that specialize in the treatment of specific medical specialties (Psychiatry, Orthopedics…etc.) or medical populations (Pediatrics, Primary Care…etc.). Over the course of each rotation, I will also need to document at least 25 patient encounters per week, track performance of a variety of procedures (required to graduate and including things like rectal exams, history/physicals, Pap smears, injections…etc.), and submitting board review practice questions in preparation for my certification exam, which I plan to take early next summer. Every four weeks, regardless of rotation, we also must report back to school, called a “callback” day, to submit the work we have been completing at each site, and also to take a comprehensive exam that covers information pertaining to the rotation specialty. For example, after four weeks of my Psychiatry rotation, I will have to pass an exam that questions me on any topic pertaining to Psychiatry (literally, anything of relevance…). For each rotation, I will be paired with a preceptor/supervisor (an MD or PA) at the site who specializes in the field, and who must sign off on any documentation/medical intervention I plan to write or administer to patients. Based on the graded assignments, callback exam, and grade given to me by my preceptor, I will receive a grade for each separate rotation. So, as it appears, each rotation entails much more than just showing up to my site every day; there seems to be a lot of work that I will still have to come home to every night/morning (if overnight shifts) as well…

As of now, I begin my clinical year with a four week Psychiatry rotation, and I definitely plan to blog at least twice (halfway through and at the completion) over the course of the next month. There is definitely nothing I will or can legally say about the site or patients, but I’m sure I’ll have plenty to say about my personal experiences/feelings about the rotation in general and any cool procedures I get to observe/assist/perform throughout the month. Over the past two weeks I’ve been brushing up on a bunch of psychiatric disorders and especially reviewing medications (most of which have a huge list of side effects), but there’s only so much I can look over before Monday, when I start. Before starting the didactic phase, I remember saying that I was anxious (85% excited, 15% nervous), but my feelings entering the clinical phase have changed just a bit…I’m still anxious, now more like 75% nervous, 25% excited. It’s undoubtedly going to be an interesting year!

Psychiatry question of the week: Can you list three signs/symptoms of depression?

Last week’s answer: The most common cause of syncope (fainting) in patients younger than eighteen years of age is low blood sugar levels (from skipping meals).

Clinical Phase Countdown: 2 days, 7 hours, 20 minutes

Graduation Countdown: Coming soon…

Weeks 56, 57, & 58: So Close, Yet So Far

It’s just about that time – the course material is piling on and finals are just around the corner. I feel a bit differently though, not so much stressed, but rather anxious. Yes, with every day that passes I inch closer and closer to exams week (last final exam week ever!), but also to encountering my first real patients out in the field. I’ve never felt any more ready for this change…so close, yet there’s still so much to get through before then.

As you can imagine, we have covered a ton of topics over the past few weeks (haven’t had a solid hour of freedom, even to write a blog, until now!). In Clinical Skills, we learned how to perform a FAST (focused assessment with sonography for trauma) exam on each other, which is an ultrasound assessment used in the emergency setting to assess for blood or fluid collection in the chest (around the heart), abdomen, and pelvis. The procedure takes no more than 5 minutes to complete, but it’s such an important and life-saving exam to master. We also learned how to use ultrasound to assess vessels of the neck (carotid and jugular) and the thyroid gland, in addition to aid in the insertion of IVs into vessels. It’s much easier to insert an IV into a vessel using ultrasound, as you can actually watch (on the ultrasound screen) the needle/catheter as it approaches and enters the vessel that you are targeting. We also learned how to insert nasogastric (NG) tubes into patients. A nasogastric tube is inserted through a nostril of the patient and advanced through the nose, down into the mouth, through the esophagus, and into the stomach (or even as far as the intestines), for purposes such as feeding. Lastly, this week, we learned how to acquire EKG readings on one another. It’s one thing to have interpreted hundreds of EKGs up to this point, but actually knowing how and where to place the electrodes on the patient to acquire the lab test is pretty important too! I really appreciate this class in that it’s a great break from reading textbooks, articles, and lectures, and focuses more on the hands-on skills that we’ll be performing on patients in about five weeks from now.

Besides the hands-on skills learned over the past few weeks, the books haven’t remained closed in all my other courses. In Emergency Medicine, we’ve learned how to manage a wide variety of drug toxicities/overdoses/withdrawal symptoms that patients may present with to the ED. Many drugs have a single antidote (treatment that stops the action of the toxic drug), but the treatment for other toxicities are fairly complex. This week, we focused on the treatment of trauma patients, specifically those who present with trauma to the head, spine, chest, abdomen, and skin (burn victims). Time is definitely not on our side when treating patients with these traumatic injuries, and I’m sure I will see plenty of cases such as these while out on my emergency rotation. In Family Practice, we learned how to work-up patients who present with abdominal pain, muscle/joint aches, and syncope (fainting episodes). We have also started to learn about the seemingly treacherous task of billing for services provided to patients. I’m honestly shocked by the intricacy of the process and also by how many hundreds of billing codes exist based on procedures performed, diagnoses made, questions asked, time spent with the patient…it’s incredible. In Pathology, we learned the processes of diseases affecting the urinary, reproductive, and endocrine systems, in addition to the skin. Finally, in Pediatrics, we’ve been focusing on the diagnosis and treatment of respiratory, cardiology, and gastrointestinal conditions in this younger age group. Again, most of these conditions are diagnosed and managed similarly in adulthood, so it’s an awesome review of past information (with enough new information to keep me busy).

Rotations truly became real last week after our clinical rotations orientation. We were loaded with information pertinent to the next year of our lives, and this was just as stressful as the orientation day leading up to my first week of PA school, about 1.5 years ago. The clinical year will entail much more than just showing up to our assigned site each day throughout the four or eight week cycles; there is also a lot of work and outside studying we’ll be doing in the spare time that we have. Our work weeks are, on average, 60-80 hours (some will be more like 7 am-5 pm work days, like in offices, others will require 24 hour on-call shifts, like surgery and OB/GYN), so I’m not quite sure where I’ll fit this “spare time” into my schedule, but that’s part of the fun of rotations I guess. I’ll give some more details about my clinical year later next month. First, I have a couple more weeks to push through…

Question of the week: What is the most common cause of syncope (fainting) in patients younger than eighteen years of age?

Last week’s answer: Your patient presents to the emergency department with a dislocated forearm bone. You should take an x-ray of your patient’s forearm before AND after the splinting process.

Clinical Phase Countdown: 38 days, 1 hour, 22 minutes

Weeks 54 & 55: Change Is Coming

I cut a long piece of cloth, resembling the texture and shape of a sock. I asked my ‘patient’ (a classmate) to hold her arm still as I slid the cloth over her hand and halfway up her arm. I then wrapped several layers of a cotton-like material over the “sock” on my patient’s arm, and prepared for the application of her arm splint (similar to a cast, but not encircling the entire limb). I then stacked eight sheets of plaster, which resembled the same size and shape of a piece of printing paper, and dipped the stacked sheets of plaster into a bucket of warm water. Placing the dampened plaster over the right side of my patient’s right arm, I molded the plaster splint around her forearm and thumb (since I was treating her for a lower thumb fracture). After several minutes, the plaster began to solidify, and I applied a few final layers of coverage (elastic bandages). Just like that, I had splinted by first (imaginary) fracture!

As is apparent, this week in Clinical Skills we learned how to splint a variety of bone fractures. Applying a splint is actually much easier and quicker than I expected it to be, only taking about ten minutes. From finger, wrist, and forearm fractures, to ankle sprains and lower leg dislocations, we practiced a good amount of splinting on one another. I splinted one arm and one leg of my partner, and she did similar forms of splints on my limbs as well. Something tells me this process will be a bit more difficult to perform on patients with actual fractures…those who I can’t tell to lift their arm or to keep their hand straight throughout the procedure, as we were able to say to one another during these practice runs.

The past two weeks have been gratefully manageable. In Emergency Medicine, we have been focusing on treatment of patients who present to the ED with endocrine emergencies, like diabetic (high/low blood sugar levels), thyroid, and adrenal gland emergencies. In Family Practice, we reviewed/learned how to work-up patients who present with fatigue, urinary tract infections, tick-borne diseases (Lyme disease), sexually transmitted infections, and infections of the skin (MRSA and fungal infections). Pathology has shifted focus to the study of the causes, manifestations, and microscopic appearances of a variety of gastrointestinal tract diseases, including diseases of the liver, gallbladder, and pancreas. Finally, in Pediatrics, we have started focusing on the diagnosis and treatment of HEENT (head, eyes, ears, nose, and throat) conditions in children. Since many of these conditions manifest similarly in adulthood, the past couple of weeks have been a great review of what we have covered over the past three semesters.

This semester is flying by! Only five weeks of classes stand between me and the completion of this first phase of PA school, and I am getting so anxious for the change that’s about to come. The next couple of weeks will get a bit crazy, mainly because I’ll have two eight hour days to endure this coming weekend, for a Radiology (x-rays, CT scans) review course on Saturday, and my clinical year orientation on Sunday. It’s never a good thing to lose a whole weekend, especially when it’s the only time available to catch up with the previous week’s material…but, too little time left to start complaining now!

Question of the week: Your patient presents to the emergency department with a dislocated forearm bone. When should you take an x-ray of your patient’s forearm? Before splinting, halfway into the splinting process, or after splinting (more than one choice may apply).

Last week’s (midterm) answers: True; Motor vehicle accidents; Subcutaneously; False; Endocrinology

Clinical Phase Countdown: 57 days, 1 hour, 35 minutes

Weeks 52 & 53: The Final Spring Break

At last, spring break has arrived (my last spring break ever), and, needless to say, it has been great to relax a bit especially after midterms. The past few weeks got a bit hectic (main reason why I never had a chance to post a blog), but all of my midterms went smoothly, and my research group (for my Master’s degree) received IRB approval (the institutional review board of the college) to move forward with conducting our research study. So, I’m nearly ready to get back to school and finish these final seven weeks. It feels so great to be able to say that…

In the final week leading up to midterms (Week 52), each course covered one final bit of information (more than a bit, I guess) before exam time. In Emergency Medicine, we focused on the treatment of neurological emergencies (stroke, seizures, head trauma…etc.). In Family Practice, we reviewed the outpatient work-up and treatment of hypertension, chest pain, and chest palpitations. In Pathology, we learned the cause for and manifestations of various forms of anemia and leukemias/lymphomas. Pediatrics shifted focus from infant care to toddler and adolescent care, focusing on psychiatric disorders (depression, schizophrenia, conduct disorder…etc.). The newest procedures learned in Clinical Skills, included urinary bladder catheterization and airway management (intubation). It’s so awesome to finally learn the steps for performing these procedures. Of course, we practiced these two procedures on anatomically correct models, and not real patients, but it will definitely help knowing these steps once I’m out on rotations. Finally, for my Clinical Decision Making course, my group received our next medical case to solve. This time our patient presented to the emergency department with fever and fatigue…and that’s all the clues we got, so this case will definitely take a more extensive work-up to figure out what’s actually going on…

As far as the research project that my group and I can finally move forward with, data collection will most likely begin at the end of this month or early next month. As alluded to a bit last semester, our research topic involves anterior cruciate ligament ((ACL) a ligament within the knee joint) injuries and their high prevalence in college level athletes. Although many of these injuries occur following direct trauma to the knee, most actually occur without contact to the knee, which suggests that such injuries are preventable if the muscles and ligaments, which support the knee, are strengthened through training and exercise. So, my research group has found a training program researched and designed specifically to prevent ACL injuries in athletes by strengthening the structures supporting the knee joint. We seek to survey college coaches (2,000 +) of soccer, lacrosse, basketball, and skiing teams (these are the sports with the highest rates of non-contact ACL injuries) across the nation to see how many of the components of this ACL injury prevention program they integrate into the training regimens of their own teams. If there is an identified correlation between the extent of the prevention program used and the number of ACL injuries that have occurred on each team, then we hope to be able to recommend implementation of this program or others of the like to help prevent these avoidable ACL injuries. With time lost, money spent, and significant medical recovery following an ACL injury, such cost-effective and successful ACL injury prevention programs may benefit all athletes of high-risk injury sports. We’ll see how this progresses over the next year…

I survived my midterms, so here’s a midterm for you:

  1. True or false: Atrial fibrillation exhibits a faster heart rate than atrial flutter.
  2. What is the most common, preventable, injury-related cause of death in children?
  3. Insulin injections are given: intradermally (into the skin), subcutaneously (between the skin and the muscle), or intramuscularly (into the muscle)?
  4. True or false: It typically requires the same amount of compression time to stop bleeding from a vein relative to an artery.
  5. Bonus: What specialty did I choose for my elective rotation?

Last week’s answer:  You just completed an arterial blood draw on your patient. After withdrawing the needle from the artery, you should apply at least 10 minutes of pressure over the puncture site (on average, but varies from patient to patient).

Clinical Phase Countdown: 71 days, 6 hours, 52 minutes (getting just a bit more eager)

Weeks 50 & 51: The Resuscitation

I, and three of my other classmates, stood beside our ‘patient’ (a mannequin simulating a real patient), and prepared for our practical assessment, which we would all have to pass to acquire our advanced cardiac life support certifications. Rotating as team leaders we would each have to lead each other through the resuscitation of a patient undergoing a cardiac arrest, with each team member performing a specific task (providing ventilation/intubation, chest compressions, and/or administering intravenous medications). The instructor informed me to assume my position as team leader, and my practical began…

My patient was an elderly male, presenting to the emergency department with chest palpitations. The instructor held an iPad, which displayed all of the patient’s vital signs and his EKG rhythm. There was also settings available if/when it became necessary to defibrillate/cardiovert (reset the heart rhythm) the patient. My patient initially presented with atrial flutter (a rapid, abnormal heart rhythm), so I initially instructed my team members to administer the appropriate medication in an attempt to slow the rhythm. Unfortunately, the treatment of this patient was not as simple and quick as giving a single dose of medication. Before I completed my practical, this same patient experienced a myriad of other rapid, abnormal heart rhythms, lost his pulse a couple of times, and then finally after chest compressions, air delivery, medication pushes, and several rounds of re-setting his heart rhythm (with shocks), the patient revived and his vital signs stabilized. It was a long five minutes, but it was such a cool simulation…

Over two Saturday sessions, nine hours each, my classmates and I attained our advanced cardiac life support certifications, which we needed prior to starting rotations. We all received our basic life support certification (CPR) prior to beginning PA school, but advanced life support adds medication use, EKG monitoring, and more invasive methods of breathing aid (intubation) to the mix. As described above, at the end of the course, each of us had to demonstrate that we could lead a team through the resuscitation of a “pulseless” patient with the information we learned. I always marveled (and still do!) at dramatic scenes of medical TV shows, especially at how the clinicians know exactly what instructions to give, equipment to use, and medication doses to prepare, in an attempt to revive a patient. It was just so surreal to be given the task of performing similar actions in this setting.

Aside from the extra weekend time spent at school, we covered a lot (what else is new?) of new information in each course. In Emergency Medicine, we focused on the treatment of infectious disease emergencies (fever, meningitis, skin infections, HIV exacerbation and associated infections), as well as OB/GYN and reproductive emergencies (testicular torsion, ectopic pregnancy, emergency delivery…etc.). In Family Practice, we focused on outpatient treatment of diabetes and thyroid disease. In Pediatrics, we continued to focus on infections that can occur throughout infancy, in addition to genetic syndromes (Down syndrome, Turner syndrome, Marfan syndrome…etc.). In Pathology, we focused on the causes and derivations of cardiovascular and respiratory disease states. Finally, in Clinical Skills, we learned how to perform arterial blood draws (used mainly for assessing oxygen and carbon dioxide levels). We did not practice this on each other, as we did for drawing blood from veins, because this procedure is a bit more painful, and also has an increased risk of bleeding (since the blood within arteries is of a higher pressure relative to veins). Instead, we practiced on arm simulators with fake blood and pulses.

Already six weeks of the semester are down! Midterms are right around the corner…

Question of the week: You just completed an arterial blood draw on your patient. After withdrawing the needle from the artery, approximately how long should you apply pressure over the puncture site? 30 seconds, 10 minutes, or 45 minutes

Last week’s answer: You just received an injection of your annual influenza vaccination. This injection was an intramuscular one.

Clinical Phase Countdown: 93 days

Weeks 48 & 49: The Blood Draw

Although I couldn’t see the normally blue-colored vein of my ‘patient’ (a classmate), once I tied the tourniquet around his upper arm, I observed a distinct bulge develop beneath the skin overlying his inner elbow. As I gently pressed over this bulge, it became clear that I was touching my patient’s vein, which was notably distended, elastic, and bouncy. I next popped the cap off the needle I would be using to draw a sample of blood from my patient. Positioning the needle slightly below the vein I aimed to puncture, I quickly penetrated the skin at a 30-degree angle, attached a test tube to the end of the needle, and watched as the test tube filled with my patient’s blood. As quickly and painstakingly nerve-racking as that, I had performed my first ever, successful venipuncture.

As is apparent, we have begun learning procedural techniques in my Clinical Skills course. The past two weeks have focused on blood drawing and insertion of intravenous (IV) tubes. The blood draw I described above was my second attempt on a classmate. My first attempt did not go as smoothly as the second…I got a blood sample, but I entered the skin at too low of an angle, so it took a bit of re-positioning of the needle to actually puncture the vein before the blood started flowing into the test tube. Drawing blood really is not that difficult. The first misperception I had though was that if you are able to visualize a vein, it would be much easier to draw blood from it, but this is definitely not the case. The only time you can be somewhat comfortable before puncturing a vein with a needle is if you can actually feel the bulge and bounciness of the vein, otherwise there is no way to predict how far to penetrate into the skin, and the likelihood of passing a needle into a flat vein is slim to none. Inserting an IV tube into each other proved to be much more difficult. This technique is no doubt going to take a bit more practice to master. In addition to drawing blood and inserting IVs, we practiced performing intradermal (into skin) and intramuscular (into muscle) injections, not on each other, but rather on an orange. The peel of the orange served to mimic the thickness of human skin, so when practicing intradermal injections, the needle did not pass any deeper than the thickness of the orange peel. For intramuscular injections, about an inch and a half of the needle was directed straight down into the orange. It was nice to take a break from poking each other with needles for two weeks and rather use a fruit. Fortunately, the orange won’t suffer from bruises and soreness for days following the practice!

All of my other classes have continued over the past two weeks as usual. In Emergency Medicine, we learned how to manage patients who present to the emergency department with shortness of breath and those who present with acute abdominal pain. In Family Medicine, we reviewed the outpatient work-up and treatment for respiratory complaints (cough, asthma, COPD…etc.), anxiety/depression, back pain, and peripheral arterial disease. In Pathology, we learned the process of wound healing and scar formation, as well as the formation and metastasis of various cancers, and the formation of vascular diseases (for example, atherosclerosis). I really appreciate this course in that it reviews all of the disease processes we have learned how to diagnose and treat over the past one and a half years, but focuses on the “what,” “how,” and “why” of each disease process. It’s extremely important to understand these disease processes to be able to communicate these important facts effectively to patients. In Pediatrics, we’ve been focusing on newborns and potential complications that may occur soon after birth (infections, birth trauma defects…etc.). In Clinical Decision Making, I’ve been working in a group with two other classmates to solve our first medical case. Our patient presented to the emergency department in the early morning with a report of severe chest pain and shortness of breath. After two weeks of questioning (history and physical), it’s nearly clear, based on the professor’s answers, that our patient is suffering from a pneumothorax (air leakage into the chest, which can ultimately collapse a lung if pressures rise high enough). We present our case, findings, and ultimate plan for this patient next week.

Overall, I cannot complain about the first month of this semester. Things will pick up a bit over the next couple of weeks. I will have to attend two nine-hour training sessions next Sunday and the following Saturday for renewal of by Basic Cardiac Life Support certification, in addition to training for my Advanced Cardiac Life Support certification. Other students have taken these courses earlier in the semester, and I’ve heard really cool things about the advanced training course, so I’m looking forward to that.

Question of the week: You just received an injection of your annual influenza vaccination. Was this injection intradermal, subcutaneous (between the skin and the muscle), or intramuscular?

Last week’s answer: Injury is the leading cause of death in children over one year of age. The two most common injuries accounting for these deaths are motor vehicle accidents and drowning.

Clinical Phase Update: This week I received the first draft of my schedule for rotations! As it stands now, the order of my rotations are: Summer: Psychiatry (4 weeks), Pediatrics (4 weeks), Family Practice (8 weeks), Fall: Internal Medicine (8 weeks), Emergency Medicine (4 weeks), Winter: Endocrinology (4 weeks), Surgery (8 weeks), Spring: Orthopedics (4 weeks), and finally OB/GYN (4 weeks). Some sites are much closer than others, but I’m content with the schedule as it stands now.

Clinical Phase Countdown: 107 days

Weeks 46 & 47: Scrubbing In

And so it has begun—my final semester of classes. I feel somewhat different about this semester. One part of me can’t wait for June and the change of pace to come with rotations, while another part of me doesn’t want to leave the classroom, but rather keep learning new material and reviewing old information for as long as I can before being thrust into the real world of medicine. But, after surviving last semester, I feel like I can get through anything at this point, especially when it comes to managing the workload. Honestly, I can’t complain about these past two weeks, but things have started to pick up a little bit, especially now that all classes for the semester have started. I’ll fill you in on what we’ve been up to…

The semester started last Tuesday with our first lecture of Clinical Skills III (the class we learn how to perform hands-on procedural skills that we’ll use in the emergency/office/and surgical settings). We learned and practiced how to scrub-in prior to surgery in addition to the order in which to don all of our protective equipment (face mask, gown, eye shield, gloves…etc.). The order and the manner in which we dress are imperative to maintain a sterile environment and ultimately avoid contamination of ourselves and, most importantly, the patient. Each week the professors observe and grade our ability, by the end of the lecture, to perform the demonstrated procedure or task, so this assessment obviously focused on our ability to dress in a sterile manner, avoiding any contamination along the way. Next week, we’ll be sticking each other with needles, so stay tuned for that story (if I’m not too bruised up to type).

The first two weeks of my Clinical Decision Making course have been interesting. At the start of each class, the professor states a complaint, as a patient would, such as “my belly hurts.” The next several hours are spent working up the patient for this general complaint. The professor says nothing unless it’s in response to a question that one of us students asks about the history and/or physical exam findings. So, we can be sitting in silence for an awkwardly long period of time. Before we order any lab tests, we must supply the professor with the reasoning behind each ordered test and also state the cost of the specific test we wish to order (insurance taken into account). With both the answers and lab results supplied by the professor, ultimately, by the end of each session, we all attempt to diagnose the “patient” and treat him or her accordingly. This class takes a lot of thought and challenges us to remember and integrate information we’ve learned over the past three semesters. It’s so great to have such a massive review.

In Family Practice (primary care for all ages), we have been focusing on immunization schedules for adults, in addition to reviewing the work-up for complaints such as headaches and sore throat (more welcomed review!). Last week in Pediatrics, we focused on assessments and screening tests indicated for children based on their age, in addition to milestones that we would expect to observe in children of varying ages. This week of Pediatrics focused on the diagnosis and treatment of vaccination-preventable diseases (measles, rubella, tetanus, hepatitis…etc.). In Pathology, we learned the mechanisms of cell death and acute/chronic inflammation. Finally, in Emergency Medicine, we learned how to work-up a patient who presents to the emergency department with a complaint of chest pain. All of the EKG practice I did last year definitely helped with this week’s lecture!

These two weeks flew by (the one snow day this past Tuesday didn’t hurt either). I’m sure things will get just a tiny bit more hectic, but I really feel like the next 13 weeks will be bearable, at least from what I’ve heard. We’ll have to see…

Question of the week: Injury is the leading cause of death in children over one year of age. What are the two most common (and most importantly, preventable) injuries accounting for these deaths?

Last week’s answer: Atrial fibrillation exhibits a faster heart rate relative to atrial flutter.

Clinical Phase Countdown: 122 days

The End: Didactic Phase, Semester Four

About one and a half years ago, I wrote my first blog post titled “The Beginning.” And now, eighteen months later, it’s already the beginning of the end of my didactic phase of PA school. A mere fifteen weeks of classes remain, in which time we will learn all material that is left to cover, before meeting our first, real patients in June. So, as usual, I am anxious to begin this final semester of classes. But, unlike at the time of my first post, this anxiousness is not comprised of both excitement and nerves, but rather just excitement. I cannot believe how far along I already am in the schooling, and, come June, I’m sure I will be ready for the next chapter of the program to begin. Let me fill you in on what’s to come in these final fifteen weeks of classes…

I will be taking a total of fifteen credits this semester, and, from what I have heard from both upperclassmen and professors about this semester, it’s notable as one of the easiest to handle. The courses left to complete include Emergency Medicine, Family Practice (outpatient care), and Pediatrics (medical management of children). Other courses include Clinical Decision Making, a discussion-based class, which will integrate all that has been learned over the past three semesters, Clinical Pathophysiology (study of the basis of diseases, down to their molecular/cellular mechanisms), and our second (of four) research class, in which we will continue to progress in the conduction of our Master’s degree research study. Finally, we will complete the last of our three Clinical Skills classes. As described in past posts, the Clinical Skills classes in the second and third semesters focused on the hands-on physical examination techniques that we will use to diagnose patients. This final Clinical Skills course will focus on procedural techniques that we will use in practice, such as suturing wounds, casting fractures, IV insertion/drawing blood, performing imaging procedures, like ultrasound…etc. It should be fun/a bit painful using each other as patients this semester, but the more practice, the better! I’ll have good stories to tell each week about this class no doubt…

And that’s all of the courses. This semester is one massive review of all the information covered in the past three semesters. Each class will incorporate and build on the knowledge we have thus far acquired, and so I am looking forward to the review. Also, at last, we have Friday’s completely off! In fact, my weekends begin Thursdays after 1:00 pm. I’m sure the course material won’t be any easier than in the past, but I will undoubtedly have more time to dedicate to each class, especially relative to last semester. Though, I’m sure I will be taking advantage of all of that extra time!

I begin this semester next Tuesday. In the mean time, here’s a question to keep you busy:

Question of the week: Which abnormal heart rhythm exhibits a faster heart rate, atrial flutter or atrial fibrillation?

Clinical Phase Countdown: 138 days

Weeks 43, 44, & 45: Three Down, One More To Go

Note: The “patients” I speak of are paid actors/actresses, hired to simulate real patient encounters for us students.

Three Fridays ago, at 4:00 pm, I stood outside exam room number 7 and waited for the cue to knock on the door, enter the room, and meet my first patient of the afternoon. When that time came, I introduced myself to the patient, a middle-aged female. Upon eliciting her chief complaint, she reported that she had been experiencing bouts of pain directly below for her right elbow, which occasionally radiated down the side of her forearm. For this encounter especially, it was most important to inquire about her occupational history, which included working as a landscaper at a local botanical gardens, in addition to coaching tennis on the side. It was nearly clear after eliciting this history, that this patient had a case of “tennis elbow,” which is irritation of some of the tendons surrounding the elbow joint, following repetitive bending motions at the wrist (as with tennis). The physical exam was fairly simple and only required a few tests to help rule out other potential diagnoses and to help support what I suspected the issue to be. After recommending an elbow brace and a higher dose of ibuprofen (for her pain), I exited the exam room and completed my first patient encounter of the day.

On this same Friday, at 4:30 pm, I introduced myself to my second patient, another middle-aged female. While decorating for Christmas over Thanksgiving weekend, she lost her footing while placing outdoor lights on her bushes, and twisted her ankle in the process. I asked her to remove her socks so I could examine the region, and her left ankle was noticeably bruised (the lab actually placed fake bruises on the patient, so there was something identifiable). Once again, it only took a few tests to help support my suspicion of a lateral ankle sprain. The patient was concerned that she had fractured one of her ankle bones, but she was able to walk with little to no support, so this decreased the likelihood of a fracture. After recommending that she continue to apply RICE (rest, ice, compression, and elevation) to the ankle for symptomatic relief, I exited the exam room and completed my last patient encounter of the semester.

In the final weeks of the semester, we completed our Neurology specialty focusing on movement disorders (Parkinson’s disease for example) and peripheral nerve disorders (Lou Gehrig’s disease, Guillain-Barre syndrome, myasthenia gravis…etc.), and our Rheumatology specialty focusing on systemic joint disorders (lupus, psoriatic arthritis…etc.). Pharmacology focused on prescription writing, specifically how to fill out a sheet of prescription paper (eventually most scripts will be in an electronic form though). Surgery focused on subtopics including ophthalmic (eye) surgery and cardiac surgery (techniques used to perform bypass surgery, heart valve replacements, and correction of heart defects of infants present at birth, such as tetralogy of Fallot). The last couple of weeks of Gynecology focused on gynecologic malignancies (breast, ovarian, uterine, vaginal, and vulvar cancers). So, unsurprisingly, the last couple of weeks of classes were no less jam-packed than any of the others.

And so, eleven classes later, I have at last completed my third semester of PA school, and boy did it live up to its reputation as being the most stressful and busy of the semesters thus far. Luckily, all of my finals went well, and the time I put into each class paid off once again. I don’t know how I made it through 15 weeks like this, retaining my sanity along the way (kind of), but all that matters is that it’s over and I’m now officially 50% done with PA school! Next semester, I’ll be taking three fewer credits and I will supposedly have Fridays off, which would make time constraints a bit less daunting. Semester four, the last semester of classes, is basically a massive review of all topics that we have covered over the past three semesters, which will be much needed because I’ll be meeting my first real patients on rotations in a mere 162 days. I’ll give more details about semester four next month. For now, it’s break time!

Last week’s answer: False. Alcohol is a depressant.

Weeks 41 & 42: Count Back From Ten

At last, Thanksgiving break is near, and I cannot wait for the extra time off to relax and to try my best to catch up with the seemingly endless load of work that I must complete prior to the end of this semester. It’s amazing how little time remains in this semester (three more weeks!), and how many more exams I must get through before I truly experience a month of freedom. But, before I get too caught up in what’s to come in my near future, let’s look back at the events of the last couple of weeks…

One of the highlights of the past two weeks was the long-awaited approval of my research group’s thesis concept. The presentation of the thesis topic went very smoothly and the first four chapters of our thesis paper require only minimal editing before we ultimately sign an agreement with one of our professors who will mentor us throughout the remainder of the program and help us conduct the study that we have designed. I know I keep promising details on the thesis, but I will write a whole post about it soon enough. In Pharmacology, we switched focus to drugs used for procedural sedation and anesthesia. With these drugs, it’s extremely important to know their dosing regimens (based on patient’s weight), in addition to the speed at which the drugs begin working and how long they last. You never want a patient to awaken from sedation before a procedure is complete…that would be a very bad thing. Some drugs act within seconds. Before a patient reaches the number nine, after he or she begins counting back from ten and the drug has been infused, he or she has already drifted to sleep. We also learned how to calculate the necessary volume of IV fluids to administer to a severely dehydrated pediatric patient, when he or she presents to the emergency department (also based on weight). Unfortunately, we are expected to perform these calculations in our heads, without a calculator, so I’ll undoubtedly be practicing a lot before our Pharmacology final. In Surgery, we completed our Orthopedics midterm, which was thankfully much easier than the General Surgery midterm and final. I definitely needed that confidence booster. The Orthopedics midterm focused on the diagnosis and treatment of upper limb (arm and hand) fractures, and so the final will focus on fractures of the spine, pelvis, and lower limb (leg and foot). In Clinical Skills, we have been learning how to perform comprehensive physicals on specific populations of patients, like older patients and pediatric patients. It’s very different performing physicals on infants (the class demonstrations have been on dolls); everything is obviously much smaller and the patient is extremely delicate.

The specialty courses have all continued as well. We ended Psychiatry by focusing on the diagnosis and treatment of substance abuse disorders (alcoholism/drug abuse) in addition to childhood psychiatric disorders (depression, anorexia, bulimia…etc.). I took this Psychiatry final on Thursday and checked yet another specialty off my list. In Gynecology, we have been focusing on abnormalities of menstruation (painful, frequent, absent…etc.) in addition to gynecologic surgical procedures and imaging. We haven’t had Neurology for a couple of weeks, but we continue with this specialty next week. Yesterday, we began our final specialty of the semester, Rheumatology (study of joint disorders). Since we only have two weeks of Rheumatology, each class is six hours long, to compensate (usually each specialty is spread out over four weeks). So, needless to say, we learned a lot of Rheumatology yesterday, including the diagnosis and treatment of osteoarthritis, osteoporosis, gout/pseudogout, rheumatoid arthritis, and fibromyalgia. As I said a few paragraphs back, luckily I have time over Thanksgiving break to catch up with all of this!

I would offer a glimpse at what the last three weeks of my semester look like, but I’d rather not think about it myself. Let’s just say I have 13 more exams (including another standardized patient lab, a couple of papers, and quizzes that I know of) to get through between now and December 19th. It’ll be an extremely bumpy ride to the finish line, but I’m way to close to give up now.

Question of the week: True or false: Alcohol is a stimulant.

Last week’s answers: The most frequently fractured bone of the human body is the clavicle (collar bone).