Rotation 9 – Rotation Reflection
Even before starting PA school, I had a strong interest in surgery. I would “follow” and subscribe to accounts on websites such as Youtube, Instagram and Facebook that showed content of surgeries. I also would actively seek out television shows that covered before, during, and after surgeries. To get my healthcare hours, I had searched on Linkedin to find a surgical PA, and had written to her to ask if I could shadow her, as well as observe procedures in the OR. I was excited that York PA school offered a rotation in surgery, and I made sure to let our clinical coordinator know that I wanted to be placed in a hospital that would offer me the best exposure to this specialty. This led me to my surgical rotation at QHC. It was initially meant to be my 5th rotation. However with COVID, it got pushed all the way to being my last rotation. I was nervous about the hours, and about being burnt out when reaching my last rotation. Also since this rotation was one I was looking forward to from the start, I was afraid that it would not meet my expectations. After completing the rotation, I realized that my fears were unfounded, and confirmed that I really did enjoy the surgical PA position.
I originally thought that the rotation only consisted of assisting in surgeries. However, only my first day of orientation, my preceptor already told us that seeing the surgeries was the least of his concerns, and he cared more for the students to see surgical consults, as well as work in the surgical clinics. Eventually I was able to appreciate why he said what he said. It was helpful to see the patients come in with a complaint in the ED, and to learn what is considered a surgical emergency, versus what could be dealt with in outpatient. In the clinics, it was good to see patients coming in to see if they needed to have surgery performed, as well as those returning to clinic after their surgery was completed. I would see the difference between good healing scars versus bad healing scars. From that, I also learned how to care for the wound, or what may need additional surgical intervention. This rotation gave me a holistic understanding of what surgical cases look like, what a surgical department does, as well as how PAs play an integral part in it.
During the rotation, I especially enjoyed those cases where I met patients when they first came in, participated in their surgeries, followed along with their recovery on the floor, and finally was able to see them get discharged from the hospital. One such patient was a man in his late 60s, who was diagnosed with colon cancer on his right side, with possible liver metastases. His surgery was being performed since the colon cancer was close to causing an obstruction. I was able to scrub-in for his right hemicolectomy with primary anastomosis, and liver biopsy. It was the first large open surgery I had the opportunity to participate in. When the patient was placed on the floor for recovery, he was encouraged to practice early ambulation. I was amazed to see how he went from being in such severe pain and needing constant encouragement to walk enough steps to leave his room; to him having minimal pain and voluntarily walking up and down the hallways within days. I was extremely happy for and proud of him. There was a point during his recovery, however, when he was being advanced from NPO to clears, and he started having coffee-ground emesis. This caused a setback in his recovery, where he had to have an NG tube replaced, and restart his NPO/diet regimen. I found this part difficult, where it was unknown how the patient’s recovery was going, and when he would be returning home.
I hope that my preceptor and the staff noticed the way I worked differently from the other students. I went in everyday enthusiastic to learn, and wanting to participate in patient care. When some students would pout about going on small surgical consults, I would openly accept the opportunity to see the patients. For the 24 hour call days, I accepted it as a greater opportunity to learn, which I think made the time go by faster. I felt like I also had great compassion when caring for patients. In surgeries, I made sure to understand why some steps/procedures would be performed over another, and was not afraid to ask. One resident had commented during a surgery that I had good “intuition” when I was handing different instruments. It felt good to be seen and praised for how I performed naturally as a student. When I was taught to do something another way, I was also good at accepting criticism and not letting it get to my head.
Rotation 9 – Site Visit Summary
For my surgery site evaluations, I decided to prepare SOAP notes. This choice made the most sense, since everyday’s patient contact mostly consisted of the time spent during the morning rounds. Writing these notes were indeed quicker than the usual H&P’s I would prepare for my other rotations, but it was initially challenging since I needed to revisit how to write them. In the first evaluation, we reviewed my 4 SOAP notes together. I learned that a lot of the notes I put together were excessive, compared to how short and to-the-point they were allowed to be. The main parts of the note to mention were if the patient had any complaints, vital signs, focused physical examination, how clean the wound/incision sites were, any relevant I&Os, pain control, and the plan. The patients I presented on were POD#1 s/p Laparoscopic converted to open cholecystectomy, and Cholecystostomy tube removal, POD#2 s/p Laparoscopic appendectomy, POD#5 s/p Exploration Laparotomy, Enterotomy Evacuation of Phytobezoar, and an evaluation for Appendicitis.
For the second site evaluation, I had prepared an additional 4 SOAP notes, as well as 10 pharmacology cards, and 1 journal article. This time I received better feedback on my SOAP notes, as I knew better as to what were pertinent versus excessive details. I presented on POD#8 s/p Debridement of perineum (Left groin Fournier gangrene), POD#5 s/p Exploration Laparotomy with Resection Hemicolectomy and Primary Anastomosis, with Liver Biopsy, a patient Hospital Day #2 admitted for RLQ Abdominal Pain (resolved SBO), and a patient s/p Amputation of 4th Toe of Right Foot (6 days ago), I&D of Right Foot Abscess (5 days ago), Debridement of Lower Extremity (4 days ago), and Debridement of Lower Extremity (3 days ago). These were big cases that I found interesting in the latter half of my rotation. For the journal article, it was a Systematic review and Meta-analysis that compared the outcomes between laparoscopic versus open appendectomies. Its conclusion showed a larger benefit in laparoscopic surgery, with the only con of a higher incidence of intra-abdominal abscesses.
Rotation 9 – Typhon Logs
Rotation 9 – SOAP notes
Rotation 9 – Journal article
Laparoscopic versus open surgery for suspected appendicitis (Review)
Jaschinski T, Mosch CG, Eikermann M, Neugebauer EAM, Sauerland S
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145/pdf/CD001546.pdf
Within the first week of my surgery rotation, I have already come across 3 laparoscopic appendectomies. Since it seems to be such a common issue I decided to find a journal article regarding its surgical management. I came across an interesting Systematic review and Meta-analysis article published in Cochrane Library comparing 2 different approaches as described in its title: “Laparoscopic versus open surgery for suspected appendicitis”. Its objective was to compare the benefits and harms of laparoscopic appendectomy (LA) versus open appendectomy (OA). The article searched through multiple journal databases, looking for randomized controlled trials that compare the two methods, in patients with signs and symptoms consistent with acute appendicitis. The primary outcomes looked at were the pain scale on the first day, wound infections within 14 days of the surgery, and intra-abdominal abscesses formed within 14 days of the surgery. Secondary outcomes included the length of hospital stay, days until patient was able to return to normal activities, and quality of life within the 1 year of having the surgery. In total, 85 studies with a total of 9765 subjects were included in the study.
Pain intensity after surgery was less in LA (0.75/10 less than OA). In the studies that compared into the use of analgesic doses needed, 13/24 studies saw no difference between methods, but 11/24 studies show less analgesia needed in LA. LA showed half the amount of wound infections than OA, but higher incidence of intra-abdominal abscesses. In a majority of the articles, the length of hospital stay was less in LA versus OA by 0-5 days. Patients with LA returned to normal activity roughly 5 days faster than OA. Quality of life was better in LA vs OA, when measured on questionnaires that followed up on the patients 2-6 weeks after the surgery.
Rotation 8 – Typhon log
Rotation 8 – Site Visit Summary
For my Pediatric site evaluations, I presented an H&P in each. The first meeting I talked about a patient who came into the Pediatric ED due to low Hemoglobin-Hematocrit readings on blood work performed at their PCP office. The patient never had a history of anemia, but described her recent menses that lasted for 1.5 months. She was also symptomatic, complaining of an episode of syncope, as well as palpitations, SOB, and dizziness. In the second meeting, I presented on a patient I saw in the Pediatric Neurology clinic, who came in complaining of 5 months of headaches after being weaned from his anti-seizure medication Depakote. I found the case interesting, since the patient was describing tension headaches like the textbook. The neurologist explained that the headaches are likely not to be due to stopping the medication, but because of online classes due to COVID and the patient’s lifestyle (ie: poor meal/water intake, excessive screen time, and taking naps during the day). In the meetings, I also presented journal articles. The first one investigated the relationship between iron deficiency anemia and febrile seizures; while the second one investigated for a relationship between migraines and ADHD patients. Pharmacology cards were also presented in both meetings, where my classmate and I took turns quizzing each other on our medications. I found this method to be different from my other site evaluations, and found it helpful to learning.
Rotation 8 – Rotation Reflection
I had grown up with a daycare in my home since the age of 5 through my early 20s. This has given me experience with children between the ages of 2.5 to 5, but rarely in the medical capacity. I was nervous about my Pediatric rotation since we were so thoroughly taught about adult illnesses during didactic year, but only had one Pediatric course. I always had challenges with pediatric practice questions as well, especially those pediatric-predominant complaints, treatments and vaccination schedules.
In the Pediatric Emergency Department, I found it difficult to examine newborns and infants. I was nervous about how fragile they were, did not want to be the reason to give them additional stress, and was also aware of how protective parents can be of their children. I would introduce myself, and interview the caretakers. Then I would just listen to the patient’s heart and lungs, and maybe examine their skin, but the rest of the physical exam was performed by the provider. Toddler to school ages fell more in my comfort zone. I knew the importance of gaining their trust in order to get their cooperation. I made sure to do this by being kind to both them and their parents, showing interest in their interests/school, and letting them talk. With doing so, they were mostly willing to cooperate with me.
I found it especially interesting to learn the techniques used to hold children to have a proper examination. From an outsider’s standpoint, it sure can appear rough to have to restrain a fighting and crying child. At first I was apprehensive, but I reminded myself of the importance of the examination, and the need to have a thorough exam to properly treat the patient. An example of this was when a child came in for a vesicular rash on their left hand and that traveled up the arm. To rule out/in Hand Foot Mouth Disease, it was necessary to hold down the child to examine her oral cavity for lesions. Another example can be seen in infants who are brought in for fever and no other complaints. Often the ear would need to be checked for otitis media/externa, no matter how much the child fought us.
Rotating in the Neonatal Intensive Care Unit was a whole other experience. It made me see how comparably stable some of the neonates/infants were who came through the emergency room. I have never seen such young and small babies in person. They looked extremely fragile, and many sick, needing multiple IV lines, tubes in their mouths/noses, and wires connected to their bodies. I had gained even more respect for the NICU nurses, seeing how they needed to step in as both the babies’ nurse, as well as their source of food and comfort during their stay. The way they cared for the babies appeared to be second-nature for them, and was beautiful to witness.
There are more than one patient that I will carry with me. I saw many unique rashes on this rotation, including Hand Foot Mouth Disease, Scarlet Fever, Pityriasis rosea, and one from taking Amoxicillin. Interviewing these patients/parents, and seeing these cases in person helped with my learning of the conditions. On a side note, in the rotation, I was surprised by the number of psychiatric cases that passed through the emergency department. It never dawned on me where children may end up if they had a psychiatric issue. One patient I interviewed was a 10 year old girl who was brought to the emergency room due to intentionally ingesting an unknown amount of medication to self-harm. The girl spoke in low tones, barely making eye contact, but was willing to engage in conversation. She was describing stress at home, where there was a custody battle surrounding her, and that her wishes of who she would rather live with was falling on deaf ears. She said that this was a major reason why she took 4 Ibuprofen the day before, and an unknown amount of another medication prior to her emergency room visit. She shared that her cousin, 10 years old as well, was also having issues at home and was the one who had brought up the idea of taking pills. Ironically enough, it was this cousin who the patient had shared the news of her pill ingestion with; and who reported it to an adult (the patient’s aunt, who ultimately was the one who called 911). This case stood out to me because of the young age of the patient, presenting with such a serious issue. I was saddened by her story, what she had shared with me. On the other hand, during the patient’s stay, I had learned about what the adults in the patient’s life had to say about the situation, as well as witnessed the patient’s interactions with the family (ie: the patient may have been simply acting out against her parent’s split custody; the patient may be talking with friends who are bad influences – which may be the reason for the patient’s recent change in attitude from “happy” to “bitter”; there was bad blood between the patient’s parents and their paternal aunt – who may have called 911 out of spite). It made me realize how we cannot assume everything in medicine at face value, and how important collateral information and patient observation can be in their diagnoses and treatment.
In the Pediatric Emergency Department, I found it difficult to examine newborns and infants. I was nervous about how fragile they were, did not want to be the reason to give them additional stress, and was also aware of how protective parents can be of their children. I would introduce myself, and interview the caretakers. Then I would just listen to the patient’s heart and lungs, and maybe examine their skin, but the rest of the physical exam was performed by the provider. Toddler to school ages fell more in my comfort zone. I knew the importance of gaining their trust in order to get their cooperation. I made sure to do this by being kind to both them and their parents, showing interest in their interests/school, and letting them talk. With doing so, they were mostly willing to cooperate with me.
I found it especially interesting to learn the techniques used to hold children to have a proper examination. From an outsider’s standpoint, it sure can appear rough to have to restrain a fighting and crying child. At first I was apprehensive, but I reminded myself of the importance of the examination, and the need to have a thorough exam to properly treat the patient. An example of this was when a child came in for a vesicular rash on their left hand and that traveled up the arm. To rule out/in Hand Foot Mouth Disease, it was necessary to hold down the child to examine her oral cavity for lesions. Another example can be seen in infants who are brought in for fever and no other complaints. Often the ear would need to be checked for otitis media/externa, no matter how much the child fought us.
Rotating in the Neonatal Intensive Care Unit was a whole other experience. It made me see how comparably stable some of the neonates/infants were who came through the emergency room. I have never seen such young and small babies in person. They looked extremely fragile, and many sick, needing multiple IV lines, tubes in their mouths/noses, and wires connected to their bodies. I had gained even more respect for the NICU nurses, seeing how they needed to step in as both the babies’ nurse, as well as their source of food and comfort during their stay. The way they cared for the babies appeared to be second-nature for them, and was beautiful to witness.
There are more than one patient that I will carry with me. I saw many unique rashes on this rotation, including Hand Foot Mouth Disease, Scarlet Fever, Pityriasis rosea, and one from taking Amoxicillin. Interviewing these patients/parents, and seeing these cases in person helped with my learning of the conditions. On a side note, in the rotation, I was surprised by the number of psychiatric cases that passed through the emergency department. It never dawned on me where children may end up if they had a psychiatric issue. One patient I interviewed was a 10 year old girl who was brought to the emergency room due to intentionally ingesting an unknown amount of medication to self-harm. The girl spoke in low tones, barely making eye contact, but was willing to engage in conversation. She was describing stress at home, where there was a custody battle surrounding her, and that her wishes of who she would rather live with was falling on deaf ears. She said that this was a major reason why she took 4 Ibuprofen the day before, and an unknown amount of another medication prior to her emergency room visit. She shared that her cousin, 10 years old as well, was also having issues at home and was the one who had brought up the idea of taking pills. Ironically enough, it was this cousin who the patient had shared the news of her pill ingestion with; and who reported it to an adult (the patient’s aunt, who ultimately was the one who called 911). This case stood out to me because of the young age of the patient, presenting with such a serious issue. I was saddened by her story, what she had shared with me. On the other hand, during the patient’s stay, I had learned about what the adults in the patient’s life had to say about the situation, as well as witnessed the patient’s interactions with the family (ie: the patient may have been simply acting out against her parent’s split custody; the patient may be talking with friends who are bad influences – which may be the reason for the patient’s recent change in attitude from “happy” to “bitter”; there was bad blood between the patient’s parents and their paternal aunt – who may have called 911 out of spite). It made me realize how we cannot assume everything in medicine at face value, and how important collateral information and patient observation can be in their diagnoses and treatment.
