Hey all. It's been a while since we've had a post so I thought I would add something. I just started my ER rotation in Gardner, MA (Gahd-nah for those of you who may be unsure of how to pronounce it with proper New England charm). Small town - which happens to be the Furniture Capitol of New England (I definitely need to leave with an armoire or a headboard or something of the sort). So far, I have done 5 shifts of 7 p.m. to 7 a.m. My preceptor is super cool: young, tells it like it is, teaches well, lets me do things (yay sutures!!) and will tell patients to their face that they are being a pain in the ass. The night people are certainly a special type... the level of innuendo, cursing, and overall inappropriateness is both shocking and hilarious. I'm just waiting to feel comfortable enough to drop in a "That's what she said" joke. Hehe.
As far a procedures, I got to learn a figure-8 stitch to close up a guy's little wounds from his femoral artery catheterization he had undergone a few days prior. I didn't tell him (or let on) that he was the first human being to be stitched by me but it it looked damn fine, I'll tell you! It sure beat pig's feet & moleskin foam. In the same night, I got to put 7 sutures in the leg of an overweight girl who was a cutter. At least it was a nice clean cut.
I met a man, 93-years-old, who was telling me about his chest pain that was going into his back. Yikes. He ended up having a huge amount of blood in his chest from a leaky TAA. He got sent to Worcester, to UMass, to have it repaired. In the meantime, he looked pretty good and was able to tell me all about his suspenders, which were red and he called them his "fireman pair". Cute.
There was a sweeeeeet scrotal abscess the other night, from which poured a glooorrrrrious stream of pus when I&D'd. I love me some infectious fluids.
Lots of drunk people who do stupid things. Sick kids with hyper parents. Sick kids who actually need to be seen. People with asinine complaints at 3 a.m. "My toe hurts. I have an ingrown toenail"... "my eye is swollen". Waaah.
Most of the time, I half know what to do... the rest of the time, I am absolutely clueless. I have been able to answer some questions, others get a blank stare. I got to try to get blood for ABG's (I hope my wording correctly implies that I was unsuccessful), having earned my preceptor's trust in my abilities to stab people (my suturing earlier in the evening). There are only 9 shifts left (he's on vaca this week) and I am sure I will see plenty, get to do plenty. I really like it, much more than I thought I would. I am not an adrenaline junkie, so I did not look forward to this one. It is very dynamic though, which I enjoy more than the well-child checks or 3-month cholesterol checks (snooooze). He seems to think I will enjoy surgery, working with my hands more. I'd have to agree.
Later, kids. Have a blast.
Monday, May 18, 2009
Wednesday, April 15, 2009
Women's Health, Newport, NH
I had heard good things about this rotation from both Alli and Nicole, so I had high expectations. So far they are being met. Day 1, my preceptor spelled out how things were going to work. Basically, I would focus on history taking when I roomed patients, and on the pap collection when we did an annual. She would take care of the heart and lungs for the exam because she wasn't comfortable with teaching that. Fair enough.
She also gives articles (several each week) for you to read, and she will go over them with you. She makes sure that she presents material to you in a way that you are comfortable doing most basic work ups (but is not condescending).
Day 3, welcome to the OR. First I observed a lap tubal ligation, then was allowed to scrub in on a hysterectomy. Its sounds sort of pathetic (and well it probably is) but I was really excited to "assist" by holding retractors and cutting suture material. When we got towards the end of the procedure the scrub nurse congratulated me on making it through my first surgery without passing out.
The next day it was IUD insertions. Not an overly fun procedure to observe (there really isn't anything to do to assist).
Week one, done and mostly uneventful.
However, in week two things start getting interesting. For one, I got to remove one of the IUDs that we had just barely inserted. The other was one of the hysterectomy patients was spiking fevers. The wound looked good, we didn't see anything wrong, so we let her go home (this was from an office follow up). She called later saying she had a fever again and was having trouble breathing...off to the ER she went.
Since that time, we have been dealing with a wound infection and an unknown pulmonary issue. Whenever this patient is reversed after anesthesia, she crashes. Her O2 sats drop precipitously. They will be fine, then boom down to 50...or lower. So far anesthesia has done a great job of bringing her back up, but we are trying to avoid more OR time. The last reversal, she was down to 21% saturation, definitely a scary situation. Why press our luck if we don't need to?
She also gives articles (several each week) for you to read, and she will go over them with you. She makes sure that she presents material to you in a way that you are comfortable doing most basic work ups (but is not condescending).
Day 3, welcome to the OR. First I observed a lap tubal ligation, then was allowed to scrub in on a hysterectomy. Its sounds sort of pathetic (and well it probably is) but I was really excited to "assist" by holding retractors and cutting suture material. When we got towards the end of the procedure the scrub nurse congratulated me on making it through my first surgery without passing out.
The next day it was IUD insertions. Not an overly fun procedure to observe (there really isn't anything to do to assist).
Week one, done and mostly uneventful.
However, in week two things start getting interesting. For one, I got to remove one of the IUDs that we had just barely inserted. The other was one of the hysterectomy patients was spiking fevers. The wound looked good, we didn't see anything wrong, so we let her go home (this was from an office follow up). She called later saying she had a fever again and was having trouble breathing...off to the ER she went.
Since that time, we have been dealing with a wound infection and an unknown pulmonary issue. Whenever this patient is reversed after anesthesia, she crashes. Her O2 sats drop precipitously. They will be fine, then boom down to 50...or lower. So far anesthesia has done a great job of bringing her back up, but we are trying to avoid more OR time. The last reversal, she was down to 21% saturation, definitely a scary situation. Why press our luck if we don't need to?
Monday, April 6, 2009
Internal Medicine, North Providence, RI
Back from a long hiatus.
So, Sherry and I are living together in a crack-style house with mattresses on the floor, and a picture of a dead Latina girl, who I have named Rosalita (She's currently buried in the floor boards). The main source of heat is the gas stove and there are ghetto light fixtures everywhere.
The rotation is going well, it's pretty much what I thought it would be: lots of acute on chronic disease pertaining to the kidneys, heart, and lungs. Cases I have seen run the gammit, but lots of pneumonia, acute renal failure, and CHF/COPD exacerbations. I have seen guillane bare (its a French disease), stage 3 lymphoma that ruptured through the colon, metastisized lung cancer, diverticulitis, MI, C diff, endocarditis, urosepsis, VRE, CNS lymphoma, BOOP, and the list goes on.
My preceptors are both nice and easy to get along with, one doesnt like to talk about the possibility of the patient's dying, and the other is a realist and will say things like: "he going to die 2 days" or "I sent him to hospice, he is going to die in a week". Days are long, but I think it is going to be a goo rotation.
Write soon!
So, Sherry and I are living together in a crack-style house with mattresses on the floor, and a picture of a dead Latina girl, who I have named Rosalita (She's currently buried in the floor boards). The main source of heat is the gas stove and there are ghetto light fixtures everywhere.
The rotation is going well, it's pretty much what I thought it would be: lots of acute on chronic disease pertaining to the kidneys, heart, and lungs. Cases I have seen run the gammit, but lots of pneumonia, acute renal failure, and CHF/COPD exacerbations. I have seen guillane bare (its a French disease), stage 3 lymphoma that ruptured through the colon, metastisized lung cancer, diverticulitis, MI, C diff, endocarditis, urosepsis, VRE, CNS lymphoma, BOOP, and the list goes on.
My preceptors are both nice and easy to get along with, one doesnt like to talk about the possibility of the patient's dying, and the other is a realist and will say things like: "he going to die 2 days" or "I sent him to hospice, he is going to die in a week". Days are long, but I think it is going to be a goo rotation.
Write soon!
Saturday, March 7, 2009
Diary of a Mad Black Woman
Are you there God? It's me, Josh....
Oh, wrong diary....
Anywho, while I cant share the specifics over the interweb, I'll try to sumarize.
It starts with an encounter 2 weeks ago that ended in self inflicted damage, and ended with an assault and me wrangling someone up against a wall and the subsequent return to jail.
Good times.
Oh, wrong diary....
Anywho, while I cant share the specifics over the interweb, I'll try to sumarize.
It starts with an encounter 2 weeks ago that ended in self inflicted damage, and ended with an assault and me wrangling someone up against a wall and the subsequent return to jail.
Good times.
Friday, March 6, 2009
The Wonderful World of Pedi's
So...we haven't had a new post in FOREVER, so I thought I'd add one.
I'm back in New London again, but seeing tiny young people this time instead of larger old people. We've been seeing about 25-30 patients a day with no lunch breaks...crazy! I love it though, I've been able to see a lot and it's always busy.
We had a case of Fifth's disease the other day, which was kind of exciting because for some reason...I've never really had a good handle on what it actually is. I guess that's kind of a lame story...but cool to me. The pt. had the "slapped cheeks" and the lacy rash on the trunk and upper extremities, which was preceded by a cold...does it get any more textbook than that?
For the most part what we see is cough, sore throat, fever, and sometimes diarrhea...good times! Occasionally the cool cases like fifth's disease, Raynaud's, Staph. infections from dirty piercings, and RSV come up.
Overall, this rotation has been great and I've learned a ton! I'd prefer to just stay here rather than continue rotating...I guess that wouldn't work very well though would it?
I'm back in New London again, but seeing tiny young people this time instead of larger old people. We've been seeing about 25-30 patients a day with no lunch breaks...crazy! I love it though, I've been able to see a lot and it's always busy.
We had a case of Fifth's disease the other day, which was kind of exciting because for some reason...I've never really had a good handle on what it actually is. I guess that's kind of a lame story...but cool to me. The pt. had the "slapped cheeks" and the lacy rash on the trunk and upper extremities, which was preceded by a cold...does it get any more textbook than that?
For the most part what we see is cough, sore throat, fever, and sometimes diarrhea...good times! Occasionally the cool cases like fifth's disease, Raynaud's, Staph. infections from dirty piercings, and RSV come up.
Overall, this rotation has been great and I've learned a ton! I'd prefer to just stay here rather than continue rotating...I guess that wouldn't work very well though would it?
Saturday, February 21, 2009
Psycho Circus
And yes, I am a member of the KISS army.
Well, my first venture into the land of the living sure has been a unique one...
I was told of some problems they have had with students in the past about posting material on a blog (such as this one!) so my information is going to remain very general and short, as some of the extremely interesting incidents are quite identifying...
I am at Worcester State Hospital on ward 5B, which is a unit for "clients" that have been here for at least a couple months. The other area where I will spend my time is 1A, a forensic evaluation unit where people (prisoners) go to receive court evaluation.
The clients on 5B are crazy. There is a wide range of disorders, most involving some sort of psychosis or pyschotic disease (schizophrenia, schizoaffective disorder, simple psychosis, etc.). There are also some clients with borderline personality disorder. Talk about walking on eggshells... these people always think you have something against them or dislike them, while they desire strong relationships, they constantly yell everything and engage in self-mutilating behaviors, and seem like they compete with one another to see who can be the worst borderline in the hospital.
It is both boring and interesting. There isnt a lot of patient interaction, but there is a lot of observation and busy work. I did get to perform an otoscopic exam and check out a nasty boil on someones lip...oh, and I almost got bit by a patient trying to assist the nurse taking a blood pressure. Other than that, it's pretty quiet. Maybe it'll get a bit spicier when I am down on 1A.
Hope everyone else is doing well. Write soon!
Well, my first venture into the land of the living sure has been a unique one...
I was told of some problems they have had with students in the past about posting material on a blog (such as this one!) so my information is going to remain very general and short, as some of the extremely interesting incidents are quite identifying...
I am at Worcester State Hospital on ward 5B, which is a unit for "clients" that have been here for at least a couple months. The other area where I will spend my time is 1A, a forensic evaluation unit where people (prisoners) go to receive court evaluation.
The clients on 5B are crazy. There is a wide range of disorders, most involving some sort of psychosis or pyschotic disease (schizophrenia, schizoaffective disorder, simple psychosis, etc.). There are also some clients with borderline personality disorder. Talk about walking on eggshells... these people always think you have something against them or dislike them, while they desire strong relationships, they constantly yell everything and engage in self-mutilating behaviors, and seem like they compete with one another to see who can be the worst borderline in the hospital.
It is both boring and interesting. There isnt a lot of patient interaction, but there is a lot of observation and busy work. I did get to perform an otoscopic exam and check out a nasty boil on someones lip...oh, and I almost got bit by a patient trying to assist the nurse taking a blood pressure. Other than that, it's pretty quiet. Maybe it'll get a bit spicier when I am down on 1A.
Hope everyone else is doing well. Write soon!
Friday, February 20, 2009
Finally having a *blast* in Women's Health
Hey all. Tuesday began my first day in Women's Health in Brockton. First though, a quick update on my former Pedi rotation. The last time I contributed to this blog, I was complaining about not really being thrown in with patients right away. Well, eventually, I was doing lots of annual physicals for all the *kiddos* and seeing many a sick patient. I was beginning to wonder if there was anything other than the "sore throat, cough, fever x3 days" chief complaint, other than the "cough, vomiting, fever x3days" variant. Such is life in the winter with children. Yuck. I was still relatively nervous around tiny babies (namely their hypervigilant parents) but got through it all. :) All in all, I loved my preceptors and the patients seemed to like me. yay!
On to Women's Health! The first day, I was to meet the doctor in the OR for a hysterectomy. I was shown the changing room, told to change into scrubs and the nurse educator would be with me soon to show me how to scrub. Well, I learned that the single time in December practicing scrubbing was certainly not sufficient because the nurse made me feel like a fool, "your arms should be higher... you haven't scrubbed that surface long enough.... no, now rinse..... you need more lather.... you suck at life." Well, the last bit may not have actually been said by her but by my subconscious mind - but it was just as clearly heard. I got to observe two abdominal hysterectomies that day. We went to a local outpatient surgical center to watch a D&C. Good lord, what brutality that is. Dear uterus: please stay healthy so as to avoid such torture. Thank you.
Off to the office! Yes, this is a rotation with several locations. Office, surgi-center, main OR and also the local free clinic. The office is fast and he has many patients. Annual PAPs, IUDs, Colposcopies, prenatal checks. For anyone who knows me, I am not a huge fan of babies and the process of growing one but it's super fun to find the heartbeat!
The next day was the first day I got to scrub in for a surgery; a vaginal hysterectomy. I was kind of nervous, because there was a larger than usual audience that day: some second-year med students from Tufts observing, in addition to the usual crowd. So, I was the lucky duck who got to assit. About 35 minutes or so into it, I noticed that I was getting the sweat moustache under my mask. "Ew, I am so hot and sweaty..." I think to myself... "Don't be silly, hold this retractor and shut up" said myself. Ehn. Well, it wasn't too much longer before I felt a bit of cold sweat, and my hearing and vision did the "snow on TV" thing. EEHH!!! So, I said very frankly, "I am afraid I am not feeling well and need to leave, I am sorry." Retractors down. Quickly moving to nearest stool. Embarrassing but it's that or fall on my head, getting concussed AND ruining the sterile field. Everyone was really nice, offered OJ, advice, etc. I was annoyed more than anything. I realize that this has happened to everyone when first starting out but I wanted to finish assisting! It was totally fun and awesome. Next time, Gadget.
To finish the week, I observed a C-section on a whale-like woman. Sorry to be insensitive but lordy.... we went back to the office for appointments. The most memorable being a consult with a 70ish woman who is using testosterone gel for her libido. She was a riot, telling me how, "my sex life had been great until my husband passed away... I masturbate often and with this gel, I feel sexy and I want intercourse and I think I have found a partner". Wow. Awesome. I could have gone my entire life without knowing that but hey... more power to you.
The week ended with an IUD insertion for a very sensitive patient. She made me feel so bad for her that I couldn't help but hold her hand and pat her knee while she winced and cringed. Ehhh... she appreciated my support.
That's that. I'm having fun and I definitely think I could spend my days helping my fellow women with the nasty, uncomfy, yet necessary things in life.
On to Women's Health! The first day, I was to meet the doctor in the OR for a hysterectomy. I was shown the changing room, told to change into scrubs and the nurse educator would be with me soon to show me how to scrub. Well, I learned that the single time in December practicing scrubbing was certainly not sufficient because the nurse made me feel like a fool, "your arms should be higher... you haven't scrubbed that surface long enough.... no, now rinse..... you need more lather.... you suck at life." Well, the last bit may not have actually been said by her but by my subconscious mind - but it was just as clearly heard. I got to observe two abdominal hysterectomies that day. We went to a local outpatient surgical center to watch a D&C. Good lord, what brutality that is. Dear uterus: please stay healthy so as to avoid such torture. Thank you.
Off to the office! Yes, this is a rotation with several locations. Office, surgi-center, main OR and also the local free clinic. The office is fast and he has many patients. Annual PAPs, IUDs, Colposcopies, prenatal checks. For anyone who knows me, I am not a huge fan of babies and the process of growing one but it's super fun to find the heartbeat!
The next day was the first day I got to scrub in for a surgery; a vaginal hysterectomy. I was kind of nervous, because there was a larger than usual audience that day: some second-year med students from Tufts observing, in addition to the usual crowd. So, I was the lucky duck who got to assit. About 35 minutes or so into it, I noticed that I was getting the sweat moustache under my mask. "Ew, I am so hot and sweaty..." I think to myself... "Don't be silly, hold this retractor and shut up" said myself. Ehn. Well, it wasn't too much longer before I felt a bit of cold sweat, and my hearing and vision did the "snow on TV" thing. EEHH!!! So, I said very frankly, "I am afraid I am not feeling well and need to leave, I am sorry." Retractors down. Quickly moving to nearest stool. Embarrassing but it's that or fall on my head, getting concussed AND ruining the sterile field. Everyone was really nice, offered OJ, advice, etc. I was annoyed more than anything. I realize that this has happened to everyone when first starting out but I wanted to finish assisting! It was totally fun and awesome. Next time, Gadget.
To finish the week, I observed a C-section on a whale-like woman. Sorry to be insensitive but lordy.... we went back to the office for appointments. The most memorable being a consult with a 70ish woman who is using testosterone gel for her libido. She was a riot, telling me how, "my sex life had been great until my husband passed away... I masturbate often and with this gel, I feel sexy and I want intercourse and I think I have found a partner". Wow. Awesome. I could have gone my entire life without knowing that but hey... more power to you.
The week ended with an IUD insertion for a very sensitive patient. She made me feel so bad for her that I couldn't help but hold her hand and pat her knee while she winced and cringed. Ehhh... she appreciated my support.
That's that. I'm having fun and I definitely think I could spend my days helping my fellow women with the nasty, uncomfy, yet necessary things in life.
Tuesday, February 17, 2009
Surgery
Hey Everybody!!! Krupa and I are doing surgery at Brockton and we had the most amazing first day! We started at 7:30a and ended 5:30p (short day apparently). The docs are super nice! We followed one doc today and scrubbed in on 4 of his cases (Lap-Chole/Indirect Inguinal Hernia Repair/Rectal Prolapse Repair/SBO Repair). I got to control the camera during the lap-chole and bag the GB before removing it, helped remove an appendix during the SBO, cut a bunch of fascia, sutured, cauterized and even did a foley cath! And we're standing next to the surgeon the whole time! I love surgery! Anyone who has this rotation will definitely be getting the most out of it! Hope everyone's doing well.
Wednesday, February 11, 2009
Before I Return to the Land of the Living...
So, the past week or so I have been performing autopsies on and off depending if the cases allow. Most of the drug/OD cases get thrown my way, as there is little I can really screw up. On occasion, the supposedly run of the mill drug death turns into something much more interesting...
Just yesterday, we had two interesting cases. The first I was not performing, as the person had a history of von Hippel Lindau, a rare genetic disorder that is characterized by brain tumors and an increased incidence of tumors if other organs. This person did have surgery to remove cerebellar tumors and had a ventricular shunt put in, which was cool to see the tube run down the neck and empty out into the peritoneum. This person ended up having a COD listed as MI, which was pretty evident upon gross sectioning.
The second case was a person with a known history of tuberous sclerosis, yet another rare genetic disorder with tumors in multiple organ systems. Kind of strange to see two rare cases in one day. Anywho, this case was being done out of hesitation, as the person had a recent dx of a stable remus fx but the next of kin was screaming that the nursing home was at fault. Because the case didnt sound very promising, Duval let me take the lead. I got the neck, tongue, heart and lungs out without much incident, except the left lung being completely adherant to the chest wall. When it came time to remove the intestine, i reflected back the duodenum/illeum and found this large black discoloration that was seemingly in the mesentary. Turns out, the decedant had MULTIPLE, HUGE, tumors in both kidneys, enough so that there was no way to distinguish kidney tissue from tumor. The estimated weight of the kidneys were 1000 and over 2000 grams! (In case you dont know, kidneys usually weigh under 200...). What appeared to have happened, is that, one of the tumors on the right side eroded a vessel that caused bleeding into/around the kidney, and eventually death (This was clearly no boating accident...).
Today I spent all day at the state crime lab, which was not exceptionally exciting. Tomorrow, I have to give my final presentation to Andrew and Duval and then go out to lunch. Even if we dont have cases tomorrow, it still feels like I went out on a bang.
See everyone real soon!
Just yesterday, we had two interesting cases. The first I was not performing, as the person had a history of von Hippel Lindau, a rare genetic disorder that is characterized by brain tumors and an increased incidence of tumors if other organs. This person did have surgery to remove cerebellar tumors and had a ventricular shunt put in, which was cool to see the tube run down the neck and empty out into the peritoneum. This person ended up having a COD listed as MI, which was pretty evident upon gross sectioning.
The second case was a person with a known history of tuberous sclerosis, yet another rare genetic disorder with tumors in multiple organ systems. Kind of strange to see two rare cases in one day. Anywho, this case was being done out of hesitation, as the person had a recent dx of a stable remus fx but the next of kin was screaming that the nursing home was at fault. Because the case didnt sound very promising, Duval let me take the lead. I got the neck, tongue, heart and lungs out without much incident, except the left lung being completely adherant to the chest wall. When it came time to remove the intestine, i reflected back the duodenum/illeum and found this large black discoloration that was seemingly in the mesentary. Turns out, the decedant had MULTIPLE, HUGE, tumors in both kidneys, enough so that there was no way to distinguish kidney tissue from tumor. The estimated weight of the kidneys were 1000 and over 2000 grams! (In case you dont know, kidneys usually weigh under 200...). What appeared to have happened, is that, one of the tumors on the right side eroded a vessel that caused bleeding into/around the kidney, and eventually death (This was clearly no boating accident...).
Today I spent all day at the state crime lab, which was not exceptionally exciting. Tomorrow, I have to give my final presentation to Andrew and Duval and then go out to lunch. Even if we dont have cases tomorrow, it still feels like I went out on a bang.
See everyone real soon!
Friday, February 6, 2009
Pretty Much The Same
This post is from Tina, from a while back. Somehow, it did not make it on to the web (I dont know how/why, Im not that much of a nerd):
Hey all! I haven't written sooner b/c, honestly, this is my first bit of free time since we started on Monday. After reading other posts, it seems like my rotation is much the same as everyone elses. Lots of autonomy...thrown into the mix on the first day, and lots of hours....working about 12 a day. Whoo! So far, I've really enjoyed my hospital rounds in the mornings, checking out the newborns. They're just so dang cute. Haven't seen anything crazy yet, but I do know of a couple of Lyme arthritis cases that have been seen in the past year, so know that there is potential in this type of rural setting to see just about anything. Oh, on a side note, I did get to see a really rip-roaring ear infection! Bubbles actually coming out of the ear. Nice! Okay, on that note, peace out. Gotta log my Typhon data.
Hey all! I haven't written sooner b/c, honestly, this is my first bit of free time since we started on Monday. After reading other posts, it seems like my rotation is much the same as everyone elses. Lots of autonomy...thrown into the mix on the first day, and lots of hours....working about 12 a day. Whoo! So far, I've really enjoyed my hospital rounds in the mornings, checking out the newborns. They're just so dang cute. Haven't seen anything crazy yet, but I do know of a couple of Lyme arthritis cases that have been seen in the past year, so know that there is potential in this type of rural setting to see just about anything. Oh, on a side note, I did get to see a really rip-roaring ear infection! Bubbles actually coming out of the ear. Nice! Okay, on that note, peace out. Gotta log my Typhon data.
Wednesday, February 4, 2009
way up north...
Since the last time I have posted, there hasn't been a ton of excitement. After all, the coolest cases stay in the ER and don't come over to intermediate care. Plus I had the joy of catching a GI bug whcih kept me home for two days (and I am glad today was scheduled as a day off for a bit more recovery).
THere have been a lot more ear infections, URIs, some UTIs, back pain and dental pain. We had one person come in with constipation x8 days. Turns out he had a bowel obstruction, we (meaning they) dropped an NG tube, got a CT and admitted him. He is actually a really nice guy and we have been following up on him and visiting him on the floor. He even sent "his ER girls" flowers to thank us for "saving him". They were going to do a colonoscopy, but after a couple of days of abx he actually passed some stool. So they were thinking diverticulitis and planning on discharging him. Until he stopped up again, so when they did scope, they could only get up to the sigmoid before finding the obstruction. Sigh. They were supposed to perform a resection with a colostomy on Monday, but since I have been out I don't know what the result was. I know what they were thinking, but I hope it isn't the case. Anyway, I am thinking this might be an interesting case to present (I am EOR #2) so I need to find out what I need to do to get copies of films and reports.
I hadn't been getting a chance to do any procedures for a while, then Saturday hit. I was working with a different woman than normal and we almost never stopped. We didn't get lunch until after 3 in the afternoon, and dinner was at 7:30 or so. I was able to do two digital blocks. One was to remove a large splinter from under the fingernail of a kid, the other was to I&D a nasty abscess on a finger (a two-fer). I sutured an arm, and was trying to to the chin of a 5 year old until he freaked out. I ended up helping to hold him with one hand, while keeping the other sterile to hand stuff to my preceptor for the day. I will say that little kids and sutures are nota good mix! Oh, I also got to watch the ER docs reduce a dislocated shoulder on a large (muscular, not fat) guy. The normal conscious sedation was not enough to relax the muscles, so they had to call in anesthesia for backup.
I can't believe that we are almost done with this rotation! it has flown by. I definitely feel more confident than I did at the beginning, but I know I still have a lot to learn.
THere have been a lot more ear infections, URIs, some UTIs, back pain and dental pain. We had one person come in with constipation x8 days. Turns out he had a bowel obstruction, we (meaning they) dropped an NG tube, got a CT and admitted him. He is actually a really nice guy and we have been following up on him and visiting him on the floor. He even sent "his ER girls" flowers to thank us for "saving him". They were going to do a colonoscopy, but after a couple of days of abx he actually passed some stool. So they were thinking diverticulitis and planning on discharging him. Until he stopped up again, so when they did scope, they could only get up to the sigmoid before finding the obstruction. Sigh. They were supposed to perform a resection with a colostomy on Monday, but since I have been out I don't know what the result was. I know what they were thinking, but I hope it isn't the case. Anyway, I am thinking this might be an interesting case to present (I am EOR #2) so I need to find out what I need to do to get copies of films and reports.
I hadn't been getting a chance to do any procedures for a while, then Saturday hit. I was working with a different woman than normal and we almost never stopped. We didn't get lunch until after 3 in the afternoon, and dinner was at 7:30 or so. I was able to do two digital blocks. One was to remove a large splinter from under the fingernail of a kid, the other was to I&D a nasty abscess on a finger (a two-fer). I sutured an arm, and was trying to to the chin of a 5 year old until he freaked out. I ended up helping to hold him with one hand, while keeping the other sterile to hand stuff to my preceptor for the day. I will say that little kids and sutures are nota good mix! Oh, I also got to watch the ER docs reduce a dislocated shoulder on a large (muscular, not fat) guy. The normal conscious sedation was not enough to relax the muscles, so they had to call in anesthesia for backup.
I can't believe that we are almost done with this rotation! it has flown by. I definitely feel more confident than I did at the beginning, but I know I still have a lot to learn.
Tuesday, February 3, 2009
You, Me, and the OCME
Good news! I have been doing autopsies, ALL BY MYSELF! (I'm such a big boy) The only part that I havent done yet is the skull, but I think I'll ask if I can do that soon. Eventhough I havent seen any cool pathology recently, it's great being able to do a procedure from beginning to end. Do you have any idea how many people OD in this state?!?! Jesus, it's like an epidemic... and they aren't skinny heroine-chic drug addicts either, these are corn-fed, BMI of 35+ drug users.
Besides the drug deaths and myocardial infarctions secondary to coronary artery disease and hypertension, I did see a case where the person was in a car accident, but refused treatment, only to return the next day complaining of neck pain, was diagnosed with multiple cervicle fractures (including C1) only to refuse treatment again, return the following day where they were admitted, died, and was then downstairs within a matter of hours. There are several words I could use to describe this person, one starts with "fuckingstupid", they other with "fuckingmoron"...
As Bob likes to say: "Just another happy ending in the Tri-State"
Saturday, January 31, 2009
Surgery, Brockton
Since I think about 12,000 more PAs will be passing through here this year, I thought I might write a little about my time here. First off, it is AMAZING!! There are 5 docs in the group, and they are all very nice. Plus a lot of docs in the OR know you are around and are happy to let you sit in (maybe not scrub every time, but you can always observe) on something if you ask. It is very much a do-it-yourself sort of rotation; you decide which surgeries you want to see, which patients you want to round on, etc. I rarely see my preceptor except morning rounds and when I'm in on a surgery he's doing. There is also another smaller surgi-center plus the home office you can spend time at. Ask for anything and it seems like they will find a way to get it for you.
My day starts at about 5:30 when I get to the hospital and round on any patients I had in the OR the day before, or other patients I have been following. I can write progress reports in the chart if I want to. There are 5 surgical residents who are also assigned to round on patients, so you have to get there early if you want to write post-op notes on the "easier" patients before they do. The residents are also very kind and are happy for the help. Then we have rounds at 6:30 in the ICU, then we can round with the interns or do whatever. Check the board in the OR, see what's on the menu, discuss with Sam who's going to scrub for what, then we're in and out of surgery all day, usually until at least 6 pm, sometimes after 8 pm. I have gone days without seeing my kids (sleeping when I leave the house/get home).
The pimping hasn't been too bad, although the first week there were a lot of anatomy questions -- how long has it been since we had anatomy? I was barely able to identify the gall bladder. Felt like a total moron. Plus working 64 hours that week I literally had no time to study. Second week after I'd spent a few hours with Netter I felt a bit better, but like someone has already said, the pictures in the book really don't look anything like the actual body, plus there is the issue that everything in Netter is in neat planes, where in the body it's 3D. This is the hardest part for me -- I can tell the docs what the branches of the external carotid artery are, but could not identify one to save my (or the pt's) life!
They do a lot of gallbladders, hernias, carotid endarterectomies, breast cancer, bowel surgery, so you should study up on these (the surgery book is very good but the anatomy pictures in there stink), but it can wait until after your first week; I would suggest starting with basic anatomy the weekend before. It is actually helpful to study some of the prep notes. There is frequently time between surgeries so keep books in your locker (better for us gals, as all the docs are male so they won't see you) for cramming for a few minutes prior.
Sam and I have seen tons of great surgeries -- lots of choles, breast biopsies, bowel resections, hernias. Sam seems to get stuck in the (usually vascular) cases that go for 10 hours (literally), made longer by the fact that you have to wear a lead suit the whole time. As time goes on they let us do more and more -- doing more suturing this week, incisions, intubations (chat up the anaesthesiologists!!), injections, stapling the bowel in resections, manning the camera on laparoscopic procedures.
Ask the OR techs lots of questions the first week -- the hardest part is figuring out how not to wreck the sterile field, how to scrub, gown, dry your hands, glove, etc., and they are as Steiner said very protective. But after the surgery is done, ask what you can do to help them clean up, and they will be very appreciative. They are very knowledgeable and also very helpful.
Anyway hope this helps. Be prepared for long hours, but don't be nervous -- it's a great place and you will learn a lot!
My day starts at about 5:30 when I get to the hospital and round on any patients I had in the OR the day before, or other patients I have been following. I can write progress reports in the chart if I want to. There are 5 surgical residents who are also assigned to round on patients, so you have to get there early if you want to write post-op notes on the "easier" patients before they do. The residents are also very kind and are happy for the help. Then we have rounds at 6:30 in the ICU, then we can round with the interns or do whatever. Check the board in the OR, see what's on the menu, discuss with Sam who's going to scrub for what, then we're in and out of surgery all day, usually until at least 6 pm, sometimes after 8 pm. I have gone days without seeing my kids (sleeping when I leave the house/get home).
The pimping hasn't been too bad, although the first week there were a lot of anatomy questions -- how long has it been since we had anatomy? I was barely able to identify the gall bladder. Felt like a total moron. Plus working 64 hours that week I literally had no time to study. Second week after I'd spent a few hours with Netter I felt a bit better, but like someone has already said, the pictures in the book really don't look anything like the actual body, plus there is the issue that everything in Netter is in neat planes, where in the body it's 3D. This is the hardest part for me -- I can tell the docs what the branches of the external carotid artery are, but could not identify one to save my (or the pt's) life!
They do a lot of gallbladders, hernias, carotid endarterectomies, breast cancer, bowel surgery, so you should study up on these (the surgery book is very good but the anatomy pictures in there stink), but it can wait until after your first week; I would suggest starting with basic anatomy the weekend before. It is actually helpful to study some of the prep notes. There is frequently time between surgeries so keep books in your locker (better for us gals, as all the docs are male so they won't see you) for cramming for a few minutes prior.
Sam and I have seen tons of great surgeries -- lots of choles, breast biopsies, bowel resections, hernias. Sam seems to get stuck in the (usually vascular) cases that go for 10 hours (literally), made longer by the fact that you have to wear a lead suit the whole time. As time goes on they let us do more and more -- doing more suturing this week, incisions, intubations (chat up the anaesthesiologists!!), injections, stapling the bowel in resections, manning the camera on laparoscopic procedures.
Ask the OR techs lots of questions the first week -- the hardest part is figuring out how not to wreck the sterile field, how to scrub, gown, dry your hands, glove, etc., and they are as Steiner said very protective. But after the surgery is done, ask what you can do to help them clean up, and they will be very appreciative. They are very knowledgeable and also very helpful.
Anyway hope this helps. Be prepared for long hours, but don't be nervous -- it's a great place and you will learn a lot!
"Domo arigato Mr. Roboto"
Have I mentioned that I love women’s health?
What a blast I have had this past three weeks.
I’m getting clinic experience where I get to meet patients without my preceptor. I introduce myself do any exams I see necessary except the gyn exam. I then present the patient to my preceptor who then comes into the room with me and watches me do the pelvic exam. She has me do any and all swabs; PAP, GCC, and has me do a wet mount and look under the microscope to identify any critters. Way cool!!!
Mondays I am on the floor delivering babies, assisting in Cesarean sections, and post partum rounding. I also go downstairs to a pregnancy care center and visit high risk pregnancy patients. Again, I am seeing patients on my own, presenting them to my preceptor, and doing fun exams like fundal height, fetal heart tones.
During the rest of the week I am either on the floor or in the OR. I am becoming very familiar with the OR. I am scrubbing in and assisting with all sorts of GYN surgeries; vaginal hysterectomies, abdominal hysterectomies, laparoscopic myomectomies, colposcopies, D&Cs. I am suturing, holding retractors, placing Foleys…you name it.
I spent the last two days assisting in robotic assisted cases. WAY COOL!!! You prep the patient like you are doing a laparoscopic procedure with five different ports sticking out of their belly. Then we drive the robot to the foot of the operating table. It looks like an octopus. We attach the robotic arm to the ports on the patient and can then slide any tool we need into the robots arm. The surgeon is across the room in what looks like a flight simulator. He sees a 3D image and can manipulate the robots arms within the patient’s abdomen. The robotic arms are so small and maneuverable. It is amazing to watch tasks like suturing inside patient’s abdomen. Perhaps all those years of my life I have wasted playing video games may come in useful after all.
Sorry for writing so much. I am just so excited to be seeing patients again and having the opportunity to see so many neat things and I wanted to share.
I miss you guys and will see you soon.
- Richard
What a blast I have had this past three weeks.
I’m getting clinic experience where I get to meet patients without my preceptor. I introduce myself do any exams I see necessary except the gyn exam. I then present the patient to my preceptor who then comes into the room with me and watches me do the pelvic exam. She has me do any and all swabs; PAP, GCC, and has me do a wet mount and look under the microscope to identify any critters. Way cool!!!
Mondays I am on the floor delivering babies, assisting in Cesarean sections, and post partum rounding. I also go downstairs to a pregnancy care center and visit high risk pregnancy patients. Again, I am seeing patients on my own, presenting them to my preceptor, and doing fun exams like fundal height, fetal heart tones.
During the rest of the week I am either on the floor or in the OR. I am becoming very familiar with the OR. I am scrubbing in and assisting with all sorts of GYN surgeries; vaginal hysterectomies, abdominal hysterectomies, laparoscopic myomectomies, colposcopies, D&Cs. I am suturing, holding retractors, placing Foleys…you name it.
I spent the last two days assisting in robotic assisted cases. WAY COOL!!! You prep the patient like you are doing a laparoscopic procedure with five different ports sticking out of their belly. Then we drive the robot to the foot of the operating table. It looks like an octopus. We attach the robotic arm to the ports on the patient and can then slide any tool we need into the robots arm. The surgeon is across the room in what looks like a flight simulator. He sees a 3D image and can manipulate the robots arms within the patient’s abdomen. The robotic arms are so small and maneuverable. It is amazing to watch tasks like suturing inside patient’s abdomen. Perhaps all those years of my life I have wasted playing video games may come in useful after all.
Sorry for writing so much. I am just so excited to be seeing patients again and having the opportunity to see so many neat things and I wanted to share.
I miss you guys and will see you soon.
- Richard
Tuesday, January 27, 2009
Endo........Colo
First, I just want to say that I'm super excited about all the snow we're supposed to be getting tomorrow!
So, we're three weeks into our first rotation and I'm quite comfortable diagnosing sinusitis, otitis media, and URI's. Last week, however, we finally saw something different. A patient was scheduled for a procedure and had pre-op blood work done which showed an H&H of 6.8 and 22! When asked, the pt. did not have any complaints and felt fine. Needless to say, the procedure was not done and two units were transfused bringing the H&H up to 10 and 32, not great but better than it was. An endoscopy and colonoscopy were ordered to see if the source of the bleeding could be determined. Yesterday, my preceptor asked if I had any interest in watching the scopes....do I ever!!
Today I showed up for the endo/colo, which was done in the OR. While I was looking at images of the esophagus, the Z line, and other such fun endo things, one of the nurses asked if I wanted to stay for a lap chole....it was my lucky day! As far as the endo/colo...no source of bleeding was found...still stumped. The lap chole was great...I just kind of stayed in the corner, out of the way so as not to contaminate anything.
Anywho, I just thought I would share my fun for the day. When I came back from the OR, I saw a few patients, then went out for a few home visits, and then came back for a prostate exam and some OM. Just another awesome day in the office of internal medicine :)
So, we're three weeks into our first rotation and I'm quite comfortable diagnosing sinusitis, otitis media, and URI's. Last week, however, we finally saw something different. A patient was scheduled for a procedure and had pre-op blood work done which showed an H&H of 6.8 and 22! When asked, the pt. did not have any complaints and felt fine. Needless to say, the procedure was not done and two units were transfused bringing the H&H up to 10 and 32, not great but better than it was. An endoscopy and colonoscopy were ordered to see if the source of the bleeding could be determined. Yesterday, my preceptor asked if I had any interest in watching the scopes....do I ever!!
Today I showed up for the endo/colo, which was done in the OR. While I was looking at images of the esophagus, the Z line, and other such fun endo things, one of the nurses asked if I wanted to stay for a lap chole....it was my lucky day! As far as the endo/colo...no source of bleeding was found...still stumped. The lap chole was great...I just kind of stayed in the corner, out of the way so as not to contaminate anything.
Anywho, I just thought I would share my fun for the day. When I came back from the OR, I saw a few patients, then went out for a few home visits, and then came back for a prostate exam and some OM. Just another awesome day in the office of internal medicine :)
Tina, I Published Your Post!
It got saved as a draft. Maybe you were wondering why you never saw what you wrote! Hope it was acceptable!
Still Seeing Dead People
Well, there hasn't been an update in a little while so here is a quick summary of what I have been doing since last:
-Went to VT to see 14 brain dissections. The guy there gets off on these things. Was cool to see some of the pathology, like lesions that had caused paralysis, or atrophy. I really didnt know all of the names of the bodies/nuclei/whatevertheyare which made it harder to appriciate them.
-More prosections (removing the organs from the body). Everything from the Y incision and neck to the rectum (Bob still does the head/brain). Last week I was instructed to open the pericardium without cutting the heart, but when I did, blood pooled everywhere, causing Dr. Andrew to laugh at me/make some comment about doing what I was told not to. Turns out, it was a hemopericardium and the person had raging pericarditis (Take that Dr. Andrew, I knew I didnt mess up!). There was also over 2L of pleural effusion fluid and half a liter of acetic fluid in the abdomen. He had said earlier this rotation that the last time he had seen a "bread and butter" pericarditis (it gets its name because it looks like a piece of buttered bread after you have dropped it and then picked it up...), was 12 years ago in NY, and claimed that it was rare to see one...pfft!
-Yesterday, I was prosecting the organs and cutting through the great vessels when I cut into this white looking thing. When I said "Uhhh, Dr. Duval, what's this?..." she said something to the effect of "Oh no, wait, stop." Which made me think I did something completely wrong (and I had cut into the trachea...slightly), but she said that it was because I had found something. With any luck, I'll be testing positive for TB on my next PPD! (keep your fingers crossed)
-Just hours ago, I saw a burn victim, wasnt anything interesting, and then another suspected OD.
-Tomorrow, a shotgun injury.
Well, time to go. I am dead tired, but not in the same way Bruce Willis was at the end of this movie...
-Went to VT to see 14 brain dissections. The guy there gets off on these things. Was cool to see some of the pathology, like lesions that had caused paralysis, or atrophy. I really didnt know all of the names of the bodies/nuclei/whatevertheyare which made it harder to appriciate them.
-More prosections (removing the organs from the body). Everything from the Y incision and neck to the rectum (Bob still does the head/brain). Last week I was instructed to open the pericardium without cutting the heart, but when I did, blood pooled everywhere, causing Dr. Andrew to laugh at me/make some comment about doing what I was told not to. Turns out, it was a hemopericardium and the person had raging pericarditis (Take that Dr. Andrew, I knew I didnt mess up!). There was also over 2L of pleural effusion fluid and half a liter of acetic fluid in the abdomen. He had said earlier this rotation that the last time he had seen a "bread and butter" pericarditis (it gets its name because it looks like a piece of buttered bread after you have dropped it and then picked it up...), was 12 years ago in NY, and claimed that it was rare to see one...pfft!
-Yesterday, I was prosecting the organs and cutting through the great vessels when I cut into this white looking thing. When I said "Uhhh, Dr. Duval, what's this?..." she said something to the effect of "Oh no, wait, stop." Which made me think I did something completely wrong (and I had cut into the trachea...slightly), but she said that it was because I had found something. With any luck, I'll be testing positive for TB on my next PPD! (keep your fingers crossed)
-Just hours ago, I saw a burn victim, wasnt anything interesting, and then another suspected OD.
-Tomorrow, a shotgun injury.
Well, time to go. I am dead tired, but not in the same way Bruce Willis was at the end of this movie...
Thursday, January 22, 2009
Gen Med I at the VA Hospital
Well so far it is gone pretty well. I am actually in the urgent care center of the hospital so it can be exciting at times....and a little intimidating. I too was thrown in right when I started...no observation. I feel like an idiot most of the time but I am getting used to that. The staff is great. Everyone is very willing to help or teach me anything. The patients are well you guessed it....old men. I have seen 2 women in the past 2 weeks and no one under the age of 35. Mostly it's COPD exacerbations, URIs, pneumonia, falls on ice, ect.... The patients are all very friendly and don't mind students at all which I was a little surprised about. So far I have seen a pleuralcentesis and done some blood draws, an NG tube, a foley, and removed sutures from a drunk man that had them in for a month! It was pretty nasty...but still fun.
I am getting a little tired of old men but its not as bad as I thought it would be. Yesterday we had a guy come in with a HUGE bowel obstruction. We had to send him to Concord Hosp becasue we can't really tx those pts at the VA. I hope everyone else is enjoying themselves. :)
See you all in 3 weeks!
PS...No P. Callahan sightings so far....pfew! I still don't know anything about abx.
I am getting a little tired of old men but its not as bad as I thought it would be. Yesterday we had a guy come in with a HUGE bowel obstruction. We had to send him to Concord Hosp becasue we can't really tx those pts at the VA. I hope everyone else is enjoying themselves. :)
See you all in 3 weeks!
PS...No P. Callahan sightings so far....pfew! I still don't know anything about abx.
Wednesday, January 21, 2009
A Message from BEYOND THE GRAVE!!!
So, today Dr. Andrew allowed me to perform not one, but TWO dissections! You'd be surprised how easy it is to get lost amongst all the fat and connective tissue, and for the record, Netter got it completely wrong...
Not only did I actively participate in the autopsies today, I also got to go to the scene of a suspicious death. It was like CSI come to life, minus all the blue-grey filters, hot scene investigators, and sexy montage music. Other than that, just like the TV show. It was thought to be a homicide, but ended up being just a run-of-the-mill OD (suspected anyway, we wont know for a while).
Tomorrow, I am going up to Burlington (Hollah at all you Vermont people, maybe I'll see you up there!) to witness 14 brain dissections performed by a neuropathologist. I feel like I should probably brush up on my neuro anatomy/physiology, and by brush up on, I mean learn for the first time...
Hope everyone up there in the world of the living is having as a productive week as I am. Keep a look out for the next tale from, The Cryptkeeper!
Not only did I actively participate in the autopsies today, I also got to go to the scene of a suspicious death. It was like CSI come to life, minus all the blue-grey filters, hot scene investigators, and sexy montage music. Other than that, just like the TV show. It was thought to be a homicide, but ended up being just a run-of-the-mill OD (suspected anyway, we wont know for a while).
Tomorrow, I am going up to Burlington (Hollah at all you Vermont people, maybe I'll see you up there!) to witness 14 brain dissections performed by a neuropathologist. I feel like I should probably brush up on my neuro anatomy/physiology, and by brush up on, I mean learn for the first time...
Hope everyone up there in the world of the living is having as a productive week as I am. Keep a look out for the next tale from, The Cryptkeeper!
Fletcher Allen Psychiatry
Well the last week was another interesting week of new experiences.
I am starting to get my feet under my self. I was asked to do a routine exam on a depressed patient with diabetes. I thought "no problem", great an easy one. Well as I went through her family history the patient unearthed a 55 year suppressed history of a very traumatic childhood. I will not speak of it here. I have not been able to sleep for the past two nights. The patient had not spoken of it before with any of her health care providers. My psychiatrist thinks she felt comfortable with me because as he puts it "I do not know anything". He thinks I was able to put an agenda aside and just talk with the patient. Thank you, I think?
Well...I thought holy shit, so I presented the case and guess who gets to do psychotherpy daily with this patient....yours truly. I had to look up what psychotherapy meant. I am still a little unclear. Wish me luck....if the patient goes into graphic detail about this history....I may need therapy.
It is a great experience, I will never forget it.
See you all in 3 weeks and 3 days.....however I am not counting
I am starting to get my feet under my self. I was asked to do a routine exam on a depressed patient with diabetes. I thought "no problem", great an easy one. Well as I went through her family history the patient unearthed a 55 year suppressed history of a very traumatic childhood. I will not speak of it here. I have not been able to sleep for the past two nights. The patient had not spoken of it before with any of her health care providers. My psychiatrist thinks she felt comfortable with me because as he puts it "I do not know anything". He thinks I was able to put an agenda aside and just talk with the patient. Thank you, I think?
Well...I thought holy shit, so I presented the case and guess who gets to do psychotherpy daily with this patient....yours truly. I had to look up what psychotherapy meant. I am still a little unclear. Wish me luck....if the patient goes into graphic detail about this history....I may need therapy.
It is a great experience, I will never forget it.
See you all in 3 weeks and 3 days.....however I am not counting
Tuesday, January 20, 2009
Not too much PA-ing, but an adventure nonetheless.
I really honestly say that you guys all seem to be having a much more exciting couple of weeks than I am. The good thing (or bummer thing, in my case) about kids is that they are, for the most part, extremely healthy. This leaves me feeling a little empty-handed in my desire to diagnose something totally off the wall. It's a regular pediatric office, so there's physicals (which I get to do), kids with asthma, colds, strains, sprains, rashes, and various minor complaints. They are really into knowing the developmental stuff (when does baby lift head? Roll over? Throw a ball? Say 3 words? 10 words?).
My preceptor and her associates have been slow in allowing me to do more things. I think it may be just how they roll. Today I did more by myself than I have been doing, because I had to really tell them, "Hey, I want to do more!!" I don't know, maybe they've had slow and/or retarded PA students in the past (from Quinnipiac.... so who knows, haha) and don't think we're ready for it. So today was much better (especially the second half), having seen all of Dr. M's patients and presenting them all to her.
Well, I will let you know if something fun/interesting comes my way... for now it's more PE's and kids with the sniffles. Bring on the Airborne. :)
P.S.
There was a call from a 19-year-old patient (yep) with pinworms. Uh huh. Right.
My preceptor and her associates have been slow in allowing me to do more things. I think it may be just how they roll. Today I did more by myself than I have been doing, because I had to really tell them, "Hey, I want to do more!!" I don't know, maybe they've had slow and/or retarded PA students in the past (from Quinnipiac.... so who knows, haha) and don't think we're ready for it. So today was much better (especially the second half), having seen all of Dr. M's patients and presenting them all to her.
Well, I will let you know if something fun/interesting comes my way... for now it's more PE's and kids with the sniffles. Bring on the Airborne. :)
P.S.
There was a call from a 19-year-old patient (yep) with pinworms. Uh huh. Right.
Pediatrics, R.I.
Hi everyone,
Josh....putting your hand in the symphysis pubis....pervert. So it sounds like most of you are having pretty exciting rotations. I'm extremely jealous of Richard. My rotation has been good. It's a small practice, privately owned by the physician. It's just him and a medical assistant. I haven't seen or done anything extra exciting. I've been mostly shadowing him, which is getting boring, but i'm hoping he'll be letting me do some more stuff. I'm his first PA student ever, so i'm not sure he knows what we were trained to do. He didn't know i had a bachelors degree! So i did some explaining, hopefully he understands. I've seen a ton of strep throat and ear infections. I saw a couple staph skin abcesses, a 13 y.o. sexually active girl that didn't want to be on birth control, we told a 17. y.o. she was pregnant. So i've seen some interested things here and there, but it's been pretty routine. Very long days. I'm enjoying it though. It's definately been a huge kick in the pants about how little i know. I'm glad you guys are having fun. Looking forward to seeing you all again.
Joe
Josh....putting your hand in the symphysis pubis....pervert. So it sounds like most of you are having pretty exciting rotations. I'm extremely jealous of Richard. My rotation has been good. It's a small practice, privately owned by the physician. It's just him and a medical assistant. I haven't seen or done anything extra exciting. I've been mostly shadowing him, which is getting boring, but i'm hoping he'll be letting me do some more stuff. I'm his first PA student ever, so i'm not sure he knows what we were trained to do. He didn't know i had a bachelors degree! So i did some explaining, hopefully he understands. I've seen a ton of strep throat and ear infections. I saw a couple staph skin abcesses, a 13 y.o. sexually active girl that didn't want to be on birth control, we told a 17. y.o. she was pregnant. So i've seen some interested things here and there, but it's been pretty routine. Very long days. I'm enjoying it though. It's definately been a huge kick in the pants about how little i know. I'm glad you guys are having fun. Looking forward to seeing you all again.
Joe
Happy Belated MLKJ Day!
While this post isnt really about the recent MLKJ Day, I felt it necessary to wish everyone a merry one.
So, while Richard's rotation may be full of puppy dogs and rainbows, mine is not... We had a traffic victim last week who did have some really interesting pathology: The pubis symphesis, which is supposed to be joined together in the front, was seperated by at least 5 inches... I could have (and did) fit my hand between both sides of the pelvis. There was also bilateral SIJ fractures, which are very stable joints. Both of the legs were fractured in multiple places but we did not bother to actually check. She also had a AO separation which made the neck/head very loose.
When is comes time to remove the ovaries and uterus, they always open the ovaries first to take sections. When this was done, there was a large corpus luteum, which prompted me to say, "so she was menstruating... or pregnant" and sure enough, she was the latter of the two. It was only about 4-5 weeks and about 2 cm long (not considered viable), sad to see nonetheless, but also pretty interesting.
Well, hope everyone enjoyed their weekend, whether it was long or not. Good luck with your second weeks, and hopefully you wont feel as stupid as you did 7 days ago!
So, while Richard's rotation may be full of puppy dogs and rainbows, mine is not... We had a traffic victim last week who did have some really interesting pathology: The pubis symphesis, which is supposed to be joined together in the front, was seperated by at least 5 inches... I could have (and did) fit my hand between both sides of the pelvis. There was also bilateral SIJ fractures, which are very stable joints. Both of the legs were fractured in multiple places but we did not bother to actually check. She also had a AO separation which made the neck/head very loose.
When is comes time to remove the ovaries and uterus, they always open the ovaries first to take sections. When this was done, there was a large corpus luteum, which prompted me to say, "so she was menstruating... or pregnant" and sure enough, she was the latter of the two. It was only about 4-5 weeks and about 2 cm long (not considered viable), sad to see nonetheless, but also pretty interesting.
Well, hope everyone enjoyed their weekend, whether it was long or not. Good luck with your second weeks, and hopefully you wont feel as stupid as you did 7 days ago!
Monday, January 19, 2009
General Med/Family Practice
Well, it's been a rollercoaster ride! Like most of you, I was thrown in on my first day also. Fed to the wolves as I like to say. Nothing like getting pimped in front of the patient... The first few days were rough and embarrassing, but I finally redeemed myself by the end of the week. I made a dx of a C6 vertebral dislocation/nerve impingement and a rotator cuff tear on two separate pts...that impressed the doc! As most of you know...msk is my nemesis!
Besides that, most of my pts have URIs, hyperlipidemia, htn, and DM. Although, today was an interesting day. I had a guy w/a hx of kidney stones that actually presented with diverticulitis, I saw a Marfan pt, and the highlight was a pt with external hemorrhoids!!! Sweet!
I would say the hardest part is doing med consults at the local psych hospital, especially if the pts aren't verbal. But everyone's nice and very appreciative of the help. ---I don't know know about you guys, but I'm soooo exhausted at the end of the day. Thank goodness I'm not falling asleep during rotations! hahahaha. I'm not in the classroom anymore.
Besides that, most of my pts have URIs, hyperlipidemia, htn, and DM. Although, today was an interesting day. I had a guy w/a hx of kidney stones that actually presented with diverticulitis, I saw a Marfan pt, and the highlight was a pt with external hemorrhoids!!! Sweet!
I would say the hardest part is doing med consults at the local psych hospital, especially if the pts aren't verbal. But everyone's nice and very appreciative of the help. ---I don't know know about you guys, but I'm soooo exhausted at the end of the day. Thank goodness I'm not falling asleep during rotations! hahahaha. I'm not in the classroom anymore.
Sunday, January 18, 2009
Adventures in Women's Health
Hey Gang,
Well I was thrown right into the fire first day. I showed up on time in the place my preceptor told me to meet her. The only problem was she was not there. About 20min pass and there is a call at the nurse’s station. My preceptor wants me to meet her in the operating room. “Where the F_ C K is the OR?” Any way, I find my way down there, change into scrubs, scrub in, and find myself preparing to assist in a D&C. The doc explains to me that this is a very routine procedure and very rarely do thing go terribly wrong. Well…things went terribly wrong. The short story is the 20min procedure turned into a two hour procedure. The patient lost 2.5L of blood…yes…2.5L. We had to stop and get her to the PACU for fluid resuscitation. Her hemoglobin was 4.4!!! She spent the next three days on the floor recovering, but did go home.
Other than that first experience the rest of my rotation has gone very very well. I am delivering babies, assisting in C-sections, measuring effacement, dilation, and station, writing progress notes while on the floor. I am also seeing patients on my own in the clinic and measuring fundal height and fetal heart tones. Most exciting is all the experience I am getting in the OR. I have been first assist several times. I am learning all the names of the surgical instruments and have begun to ask for them by their proper name. I have done abdominal hysterectomies, vaginal hysterectomies, endometrial ablations, polypectomies, D&C, hysteroscopy, you name it I probably did it in my first week.
I am having an absolute blast!!! If the doctors in this practice had a position open to hire a PA I would apply for it in a heartbeat. The women’s health floor is so full of excitement and joy nearly everyone walks around with a permanent smile on their face. I may not want this rotation to end if it continues to be like this.
See you all in four weeks,
Richard
Well I was thrown right into the fire first day. I showed up on time in the place my preceptor told me to meet her. The only problem was she was not there. About 20min pass and there is a call at the nurse’s station. My preceptor wants me to meet her in the operating room. “Where the F_ C K is the OR?” Any way, I find my way down there, change into scrubs, scrub in, and find myself preparing to assist in a D&C. The doc explains to me that this is a very routine procedure and very rarely do thing go terribly wrong. Well…things went terribly wrong. The short story is the 20min procedure turned into a two hour procedure. The patient lost 2.5L of blood…yes…2.5L. We had to stop and get her to the PACU for fluid resuscitation. Her hemoglobin was 4.4!!! She spent the next three days on the floor recovering, but did go home.
Other than that first experience the rest of my rotation has gone very very well. I am delivering babies, assisting in C-sections, measuring effacement, dilation, and station, writing progress notes while on the floor. I am also seeing patients on my own in the clinic and measuring fundal height and fetal heart tones. Most exciting is all the experience I am getting in the OR. I have been first assist several times. I am learning all the names of the surgical instruments and have begun to ask for them by their proper name. I have done abdominal hysterectomies, vaginal hysterectomies, endometrial ablations, polypectomies, D&C, hysteroscopy, you name it I probably did it in my first week.
I am having an absolute blast!!! If the doctors in this practice had a position open to hire a PA I would apply for it in a heartbeat. The women’s health floor is so full of excitement and joy nearly everyone walks around with a permanent smile on their face. I may not want this rotation to end if it continues to be like this.
See you all in four weeks,
Richard
Saturday, January 17, 2009
New London - Internal Medicine
I'm probably not doing as many exciting things as everyone else, but it's going well so far.
We see somewhere between 6 - 10 patients a day and the average patient age is around 65 years old. We've seen a lot of pneumonia, sinusitis, and influenza as well as lots of back pain! It's a very small town, so everyone knows everyone else...which makes their visits extra long because we have to talk about the neighbor's new cow or about their Aunt coming to visit. I absolutely love it though, it makes me feel at home :)
I did rounds at the SNF on Wednesday with our MD. I got to see my own patients and have a great chat about Bingo at the home. I love geriatrics...they're great. Then I came back to the office to watch someone get their ingrown toenail removed, good times. I think the best thing I've seen so far was a liver that you could see from the doorway! It was about 10" beyond the costal margin and as hard as a rock...yikes!
On Friday, I did rounds with the Hospitalist at New London Hospital. Again, the average age of the patients that he see is 75 years old. After seeing some great surgical sites, a DVT, and some possible lung CA, he took me out to lunch in the tiny hospital cafeteria.
So far, so good...I hope everyone else is having a good time, and hopefully you remember a lot more stuff from last year than I've been able to.
Good luck!
We see somewhere between 6 - 10 patients a day and the average patient age is around 65 years old. We've seen a lot of pneumonia, sinusitis, and influenza as well as lots of back pain! It's a very small town, so everyone knows everyone else...which makes their visits extra long because we have to talk about the neighbor's new cow or about their Aunt coming to visit. I absolutely love it though, it makes me feel at home :)
I did rounds at the SNF on Wednesday with our MD. I got to see my own patients and have a great chat about Bingo at the home. I love geriatrics...they're great. Then I came back to the office to watch someone get their ingrown toenail removed, good times. I think the best thing I've seen so far was a liver that you could see from the doorway! It was about 10" beyond the costal margin and as hard as a rock...yikes!
On Friday, I did rounds with the Hospitalist at New London Hospital. Again, the average age of the patients that he see is 75 years old. After seeing some great surgical sites, a DVT, and some possible lung CA, he took me out to lunch in the tiny hospital cafeteria.
So far, so good...I hope everyone else is having a good time, and hopefully you remember a lot more stuff from last year than I've been able to.
Good luck!
Pretty Much the Same
Hey all! I haven't written sooner b/c, honestly, this is my first bit of free time since we started on Monday. After reading other posts, it seems like my rotation is much the same as everyone elses. Lots of autonomy...thrown into the mix on the first day, and lots of hours....working about 12 a day. Whoo! So far, I've really enjoyed my hospital rounds in the mornings, checking out the newborns. They're just so dang cute. Haven't seen anything crazy yet, but I do know of a couple of Lyme arthritis cases that have been seen in the past year, so know that there is potential in this type of rural setting to see just about anything. Oh, on a side note, I did get to see a really rip-roaring ear infection! Bubbles actually coming out of the ear. Nice! Okay, on that note, peace out. Gotta log my Typhon data.
Friday, January 16, 2009
Gen Med 1--Almost Canada, VT
Well, week one is over. I haven't killed anyone, or even had a problem (other than feeling like a complete idiot my first day). My preceptor is really nice, but also expects me to work. (not a bad thing). Being nervous I wanted to observe on a few patients first (even though she would have let me go straight to it). After 3-4 we had a repeat complaint..."go do it". After that I would start most patients (except when we were busy) and go present them to her. There was one I had to go back multiple times to ask more questions (oops).
Yesterday was day #2 (keep in mind I work 9am-9pm). My preceptor had to recert in PALS, so I worked with a PA named Ben. Awesome teacher! After our first patient (knee pain) he had me practice orthopedic exams on him while it was slow. Once things picked up, I would go in, take the history, present, suggest possible meds/tx. I splinted, I did a digital block on a thumb (no sutures were need though), and felt like I learned a lot. I was hoping to suture a child that came in, but as soon as he found out he needed stitches there was a meltdown. Instead I held the head while my preceptor numbed and sutured the ear. Oh yeah, I saw an amazing case of hives...4 days, all over, benadryl did nothing. Very pleasant patient, encourage me to examine them fully. Then patiently waited for the prednisone script. Apparently this happens all too often. I also saw a corneal/conjunctival abrasion, it was pretty cool how the fluorescein is uptaken by the injured areas.
Today was really slow (avg of about 1 pt. per hour). So I did almost everything on my own first. Starting off was a broken 4th metacarpal from basketball. FYI bruising on the palmar aspect of the hand is a pretty good indication of a fracture. Splinted the kid on my own, and on his way. Then dental pain x2 (one was a broken tooth, half gone and could easily see the pulp), and I was also able to observe part of an evolving MI before the pt. was transferred to Burlington.
If you are coming up here, be prepared to see lots of dental pain and back pain. There is a high proportion of medicaid patients that come through the clinic, and many haven't seen a dentist in years (if ever). Also, lots of delayed treatment. "Oh, I flew off my sled (snowmobile) about a week ago and my hand still hurts." Even kids coming in with fractures a week later...one poor kid had a partially displaced metacarpal that had already started forming a callous...will probably need surgery because of the delay.
As a bonus, I was sent home early tonight. That is, after 11 1/2 hours instead of 12. Something to do with the fact we had seen 1 patient in the past 2 hours.
Yesterday was day #2 (keep in mind I work 9am-9pm). My preceptor had to recert in PALS, so I worked with a PA named Ben. Awesome teacher! After our first patient (knee pain) he had me practice orthopedic exams on him while it was slow. Once things picked up, I would go in, take the history, present, suggest possible meds/tx. I splinted, I did a digital block on a thumb (no sutures were need though), and felt like I learned a lot. I was hoping to suture a child that came in, but as soon as he found out he needed stitches there was a meltdown. Instead I held the head while my preceptor numbed and sutured the ear. Oh yeah, I saw an amazing case of hives...4 days, all over, benadryl did nothing. Very pleasant patient, encourage me to examine them fully. Then patiently waited for the prednisone script. Apparently this happens all too often. I also saw a corneal/conjunctival abrasion, it was pretty cool how the fluorescein is uptaken by the injured areas.
Today was really slow (avg of about 1 pt. per hour). So I did almost everything on my own first. Starting off was a broken 4th metacarpal from basketball. FYI bruising on the palmar aspect of the hand is a pretty good indication of a fracture. Splinted the kid on my own, and on his way. Then dental pain x2 (one was a broken tooth, half gone and could easily see the pulp), and I was also able to observe part of an evolving MI before the pt. was transferred to Burlington.
If you are coming up here, be prepared to see lots of dental pain and back pain. There is a high proportion of medicaid patients that come through the clinic, and many haven't seen a dentist in years (if ever). Also, lots of delayed treatment. "Oh, I flew off my sled (snowmobile) about a week ago and my hand still hurts." Even kids coming in with fractures a week later...one poor kid had a partially displaced metacarpal that had already started forming a callous...will probably need surgery because of the delay.
As a bonus, I was sent home early tonight. That is, after 11 1/2 hours instead of 12. Something to do with the fact we had seen 1 patient in the past 2 hours.
General Medicine at Happy N Healthy Clinic-Salem
okay, so i messed up..umm..i added a comment to josh's thinking thas how it goes...sorry again..so i jus copy pasted it..i think i got it now!!...i feel so silly....so here's wut i originally wrote...
So....seeing i have never done this...is this blogging or just commenting to Josh?...humm...someone correct me if I'm wrong. Okay so my first rotation...IS AWESOMEEEEEEEEEEE...omg...I love it. I'm in Salem, working in a small clinic, so we don't get to see anything exciting, but my preceptor has given me pretty much full independence, well....as much as it is allowed anyways. I get to see my own patients, do all the fun stuff, dx them, and even write out their prescriptions (of course i cant sign these, but im not complaining), and get to write sick notes...i know...nothing crazy...everyone is probably doing this, but im still loving it. I even have MY PATIENTS..haha...patients i'm going to follow for the next 5 weeks. This is great. Even though we have to check in everything we do, which is annoying at times, but it's okay. Fun cases?....besides your usual yeast, alcoholic, HTN, DM, Colds,..ooh, young girl came in today with..well, can't really dx is as anything, but she normally has a lot of ectopy, but again it's nice to know, it's okay not to jump the gun everytime. So things i'm not doing so good on...THE SPEED... i feel like i'm, way to slow in seeing the patient, writing up their charts, and makind everything into an appropriate record. Maybe that is something that comes with time. Anywhoooo....I hope everyone is having an awesome time...Miss you guys
So....seeing i have never done this...is this blogging or just commenting to Josh?...humm...someone correct me if I'm wrong. Okay so my first rotation...IS AWESOMEEEEEEEEEEE...omg...I love it. I'm in Salem, working in a small clinic, so we don't get to see anything exciting, but my preceptor has given me pretty much full independence, well....as much as it is allowed anyways. I get to see my own patients, do all the fun stuff, dx them, and even write out their prescriptions (of course i cant sign these, but im not complaining), and get to write sick notes...i know...nothing crazy...everyone is probably doing this, but im still loving it. I even have MY PATIENTS..haha...patients i'm going to follow for the next 5 weeks. This is great. Even though we have to check in everything we do, which is annoying at times, but it's okay. Fun cases?....besides your usual yeast, alcoholic, HTN, DM, Colds,..ooh, young girl came in today with..well, can't really dx is as anything, but she normally has a lot of ectopy, but again it's nice to know, it's okay not to jump the gun everytime. So things i'm not doing so good on...THE SPEED... i feel like i'm, way to slow in seeing the patient, writing up their charts, and makind everything into an appropriate record. Maybe that is something that comes with time. Anywhoooo....I hope everyone is having an awesome time...Miss you guys
Thursday, January 15, 2009
Fletcher Allen Psychiatry
Well.... It has been a rough week!!!
I am with the psychiatric consult team. We respond to any psychiatric requestsin the entire hospital. The team consists of a psychiatrist, a psychiatry resident, (2) 3rd year medical students and myself.
On the first day, I looked at a white board of about 8 patients. I was then promply asked which patients I wanted. My jaw may have hit the table. I had my own patients that I round on by myself within two hours. I see these patients read through their medical charts, trying to figure out their history and why a psychiatry consult has been initiated. I may have to call their psyciatrist in the community, social worker, family members, ect to get background information. Once all the information is collected and I have interviewed the patient by myself (no help, no back-up) I present the case to my team. I then write up the case, have the resident sign my note. The note then goes in the chart. The disorders I have seen so far include anixety and depression, schizo-affective disorder with paranoia, paranoia with a TBI, acute dystonia, anorexia, hepatic encephlaopathy, and bi-polar disorder.
My psychiatrist did hypnosis on one of my patients today, that was pretty cool. The rotation is overall great...I am learning a ton, however I am totally out of my comfort zone. These patients are rather unpredictable and it is very intimidating to interview them by yourself. You are given a huge amount of responsibilty immediately, it is rather overwhelming. For those of you with this rotation be prepared to jump in right away. It is a must to know your mental status history and mini-mental exam. I do those everyday...again by myself.
Hope everyone else is doing well
I am with the psychiatric consult team. We respond to any psychiatric requestsin the entire hospital. The team consists of a psychiatrist, a psychiatry resident, (2) 3rd year medical students and myself.
On the first day, I looked at a white board of about 8 patients. I was then promply asked which patients I wanted. My jaw may have hit the table. I had my own patients that I round on by myself within two hours. I see these patients read through their medical charts, trying to figure out their history and why a psychiatry consult has been initiated. I may have to call their psyciatrist in the community, social worker, family members, ect to get background information. Once all the information is collected and I have interviewed the patient by myself (no help, no back-up) I present the case to my team. I then write up the case, have the resident sign my note. The note then goes in the chart. The disorders I have seen so far include anixety and depression, schizo-affective disorder with paranoia, paranoia with a TBI, acute dystonia, anorexia, hepatic encephlaopathy, and bi-polar disorder.
My psychiatrist did hypnosis on one of my patients today, that was pretty cool. The rotation is overall great...I am learning a ton, however I am totally out of my comfort zone. These patients are rather unpredictable and it is very intimidating to interview them by yourself. You are given a huge amount of responsibilty immediately, it is rather overwhelming. For those of you with this rotation be prepared to jump in right away. It is a must to know your mental status history and mini-mental exam. I do those everyday...again by myself.
Hope everyone else is doing well
Wednesday, January 14, 2009
First, (well second) post
Well, I guess I have to be the first to post so here goes...
The pathology rotation with Dr. Andrew (not AndrewS, there is no "s") and Dr. Duvall is pretty tit. As I said in my email to everyone, I start at a reasonable time and get done with autposies by 2pm, which leaves the rest of the day for paperwork (aka, I can pretty much leave, but I stay to make it feel like I accomplish something!)
To date, I have seen 5 autopsies and participated in 3 of them:
First day, was a known alcoholic and dropped to the ground after buying a 6-pack. Duvall agreed with me when I suggested dilalated cardiomyopathy due to EtOH, but once we removed the organs, there were large bilateral PE's that came from the left distal leg. The second was a gunshot to the chest just to the right of the right nipple. It entered at rib 4/5 and lodged in the spine at about 6/7, passing through the lung. COD was exsanguination, as there was about 2L of blood in the chest, but the manner of death Duvall said probably wont be able to be determined as there are too many factors to consider whether it was done on accident, purpose, or someone shot them...
Second day, we had an obese person who was suspected to have died of a methadone overdose. COD in OD cases takes 4-6 weeks as toxicology results take this long. The second was an elderly person who came in with bruises on the right shoulder, eye, and head, almost in a linear pattern. When we opened the skull, there was a big subdural hematoma where the injury to the head was. On both of these patients I got to practice drawing fluids from various areas: eyes, femoral vein, IVC, gallbladder, bladder, which is pretty cool for only the second day.
Today, another suspected OD, Duvall says more than 50% of the cases they see are drug related, making them pretty mundane unless there is incidental pathology, which there was in this case! I was attempting to draw bile from the gallbladder, which looked really different from the other ones I had seen. The only thing that made me positive that it was the gallbladder was the 1 inch round stone I felt while putting the syringe in.
Tomorrow we have a 20 something y/o who dropped dead. More to come on that after tomorrow morning.
Hopefully this will inspire people to follow suit and post something of your own.
Peace!
The pathology rotation with Dr. Andrew (not AndrewS, there is no "s") and Dr. Duvall is pretty tit. As I said in my email to everyone, I start at a reasonable time and get done with autposies by 2pm, which leaves the rest of the day for paperwork (aka, I can pretty much leave, but I stay to make it feel like I accomplish something!)
To date, I have seen 5 autopsies and participated in 3 of them:
First day, was a known alcoholic and dropped to the ground after buying a 6-pack. Duvall agreed with me when I suggested dilalated cardiomyopathy due to EtOH, but once we removed the organs, there were large bilateral PE's that came from the left distal leg. The second was a gunshot to the chest just to the right of the right nipple. It entered at rib 4/5 and lodged in the spine at about 6/7, passing through the lung. COD was exsanguination, as there was about 2L of blood in the chest, but the manner of death Duvall said probably wont be able to be determined as there are too many factors to consider whether it was done on accident, purpose, or someone shot them...
Second day, we had an obese person who was suspected to have died of a methadone overdose. COD in OD cases takes 4-6 weeks as toxicology results take this long. The second was an elderly person who came in with bruises on the right shoulder, eye, and head, almost in a linear pattern. When we opened the skull, there was a big subdural hematoma where the injury to the head was. On both of these patients I got to practice drawing fluids from various areas: eyes, femoral vein, IVC, gallbladder, bladder, which is pretty cool for only the second day.
Today, another suspected OD, Duvall says more than 50% of the cases they see are drug related, making them pretty mundane unless there is incidental pathology, which there was in this case! I was attempting to draw bile from the gallbladder, which looked really different from the other ones I had seen. The only thing that made me positive that it was the gallbladder was the 1 inch round stone I felt while putting the syringe in.
Tomorrow we have a 20 something y/o who dropped dead. More to come on that after tomorrow morning.
Hopefully this will inspire people to follow suit and post something of your own.
Peace!
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