bursitis, blotchy erythema (reddness), and bleeds

As I stated in the previous post, Wednesday was my first day on the ward.  After biking to and from work 4.5 miles since Sunday in 80 degree heat I was feeling the burn.  Tuesday I broke down and bought a rack and two saddle bags for my road bike.  I was experiencing pain in my left shoulder that I couldn't attribute to working out or sleeping on it.  On the ride back on Tuesday, I just thought of all really important muscles, nerves, and blood vessels in my arm and axilla.  Better safe than sorry.

For work Wednesday I packed the two saddle bags and by messenger bag with stuff.  Boy, I can safely say it was overkill.  I did have a lot of weight but it did not require three bags.  Today I'm going to try and get it down to one saddle bag and my messanger bag.

Walking into the ED for the first time on my own was exciting.  It was 11am, early, so not much was going on yet.  J, a summer medical health tech from Boston University showed me the ropes.  We started with the basic lay of the land, how to clean a room, and how to operate the beds.  Within 10 minutes I was working. In 20 minutes we had moved on to EKGs and IVs.  That's what I call on the job training.

I walked a few patients to get imaging done, ran blood work to the clinical laboratory, chatted with veterans as they waited to be seen, observed and assisted the nurses, physicians assistants and physicians if anything interesting came up.

One spinal cord patient with a brilliant mind came in with what turned out to be a bursitis on his knee.  A bursa is little sack that should have only a small amount of fluid inside to help with joints that experience a lot of friction (shoulder, elbows, hips, and knees) . The attending physician showed me how he ruled out infection or some other inflammatory processes.  We gave him a compress to push the fluid out and sent him on his way.

Another patient was who was a delight had a history of pulmonary emboli and came in because his left leg was swollen and the back of the calf was red like a bruise. It didn't cause him pain but the rapid onset was what concerned him come he make in.  This guy was great we talked about all kinds of things as I took him to get his imaging done.  From where he was born to where he served in the military and what he was up to now a days.  I really like when the conversation flow naturally.  It was pretty easy with a lot of the guys I met on Wednesday.

My last patient for the day was an African American vet who served in Korea.  He was taken to the ED from his dialysis center because he took to long to stop bleeding.  He definitely did not want to be in the hospital which I can appreciate after being on dialysis for hours on end.  It was really interesting getting to talk with him because his experiences seemed so different from the other guys I spoke with that day.  The others seem nostalgic for the good old days in the military.  He didn't complain about having to serve but his story lacked the romanticized tint of the other guys.  It was a good way to end the day.  Partly because his appearance and affect reminded me of my uncle and partly it helped me put the idea of military service at wartime back in perspective.  I'm so glad I was able to say thank you to these vets in person.

I lost track of time after the first hour.  When I looked at the clock again it was nearly 3pm and I was thinking about getting lunch in a bit.

Observation:  Most of the attendings appear to internal medicine docs.  I spoke with one and she said that since we don't usually get trauma patients coming in, the IM docs can handle the emergency room.  It made me think of an urgent care center, which is totally fine with me.  I am not looking forward to seeing trauma, but I'll be there to learn when the time comes!

Highlight: Getting to see an attending to run through the NAVEL pneumonic in actual practice and really use his senses to discover what the surgical resident simply couldn't catch.  He had palpable bruits on his right femoral artery.  The pain he suffered intermittently from was deep to the artery.  When I left at 7:30p, we hadn't figured out what caused him pain so great that he couldn't walk.  I was confident that the docs and nurses would sort it out.

Okay on to another day at the W. Rox VA

Orientation: Ethics, Autonomic Dysreflexia, med gadgets

Yesterday I started work as a medical health technician in the Emergency Department at the West Roxbury Veterans Administration Hospital.  I went through two days of orientation before I thrown on the ward. 

Day one and two were pretty jam packed with information.  I sat through hours of training on the VA electronic medical record system, infection prevention and control, ethics, and wound care.  I was fit-tested for an N95 respiratior, instructed on how to place a Foley catheter (urinary catheter), and shown in about an how to work:
a vitals monitor,
pelvic scanner,
alternating leg pressure athrombic pump,
feeding pump,
and a knee CPM (continuious passive motion) machine.

Highlights of orientation:1) passing the N95 respirator test and not having to use some funny looking mask. 2) learning about Autonomic Dysreflexia a fascinating but life-threatening condition that affects people with spinal cord injuries.

Autonomic Dysreflexia: life-threatening condition typified by hypertension, increases heart rate and respiratory rate, among other symptoms.  AD is caused by a noxious stimuli below the level of the spinal cord injury.  The SBP can skyrocket up to 300 mm Hg can damage the eyes, kidneys, lead to intracranial hemmorage and death. Noxious stimuli can be anything from a pen cap pinching the leg of the patient in bed to a full bladder due to a kinked catheter. 

I had no idea this kind of thing existed.  It sounded pretty wild but I spoke with a nurse who has seen many cases of this.  She seemed very comfortable and competent in dealing with this when it arises.  I was super impressed!

One year in...

Bittersweet anniversary of my move to Boston.  One year ago yesterday I was saying goodbye to a wonderful (and I'll admit comfortable) life in Oakland, CA for prospects unknown as HMS.  I won't rehash or further mourn what has passed.  It is especially hard for me because today is so much like last year, right down to the rain and me moving boxes. I got up this morning to help my buddy, GV, move out of the dorm.

2010 over did it on the drama.  It is June.  2010 has already brought wonderful things, the birth of beautiful babies, some of my good friends have already or will get married, health care reform was passed.  The year has also brought some sorrow, death, illness, violence and heartbreak.  At times it is more than I care to think about.  I mean, how is one to really pour oneself into the study of medicine when all this craziness is going on.  I asked myself that many times during the 2009-2010 academic year.  All I know is one must push on.  Too much is at stake.  I am missing so much back home: births, birthdays, and graduations.  I left to make a better way for my family and community.  What good am I to them if I don't do my best despite the hardships?

Second-year or MS-2.  I intend to rock next year.  To shine and help others shine too.  I intend to channel those positive So Cal vibes all the way from Boston, MA.  Who knows I might even find higher purpose.