The Weekly Sign-Out

~a documentation of my clinical rotation experience~

weeks 21-30

Week 28-30: March 7 - 27

two-thousand-and-twenty-one

The Highs:

Correctly diagnosed Shingles
Working with Ultrasound
CPR practice
Working with awesome residents!
Visiting my parents!
Driving back to Colorado with Michael

The Lows:

Overnight shifts
Saying goodbye

Overall rating of the weeks: 10/10

Let's face it. I've had the MOST amazing rotation out here in Kingman. I've gotten to see so much, DO so much, practice medicine, and learn more than I ever thought I could in just 10 shifts! Every week, Dr. Truong would put on a simulation lab for us, whether it was ultrasound with Dr. Choi and Dr. Snodgrass, learning chest tubes with Dr. Brinkerhoff, practicing central lines with Dr. Weech, or doing lumbar punctures with Dr. Jahnny, I got so much hands-on learning which was incredible. I got to work with such amazing residents who were always willing to teach, give feedback, and let me make my own decisions. I got practice ultrasounding patients at bedside, correctly diagnosed an important VIP who was seen at the Havasu hospital the day before with Shingles (they didn't look at her skin, but I did, and I saw a shingles rash!), I was able to use OMT and provide multiple patients with relief of their necks, heads, wrists, and backs, and was given a few opportunities to perform CPR to save someone's life. I had a 4 day break which allowed me to fly home and visit my parents and also look (and book!) a wedding venue for me and Michael next year. I can't believe how much I've done on this rotation, which has been a breath of fresh air. Being in the ED completely revitalizes me. It makes me feel like the job I'm doing is important. It makes me feel like I've been given this amazing privilege to help someone on the worst day of their life, and it's an absolute gift. I know this post is short. I've been behind on posting. But seriously, if I hashed out every detail of every day, this post would be the longest one ever, and would take forever to read. Haha. Take my word, if I don't match into EM, what am I even doing with my life?

Shout out to the amazing residents and attendings I've gotten to work with here: Dr. Chelsea Weisner, PGY-2, Dr. Logan Bruttig, PGY-2, Dr. Eric Batory, PGY-2, Dr. Clarke Snodgrass, PGY-1, Dr. Katie Sumpter, PGY-1, Dr. Sarah Zito, PGY-1, Dr. Shawn Catmull, PGY-3, Dr. Michaela Hasenkrug, PGY-2, Dr. Heesun Choi, DO, Dr. Stevy Merrill, MD, Dr. Shane Sergent, DO, Dr. Elisha Bremmer, MD, Dr. Jose Gochoco, DO, Dr. Brian Jahnny, Dr. Justina Truong, Dr. Richard Henderson, MD, Dr. Jeff Conley, MD, and Dr. Adam Dawson, DO.

Top: (L) Me, Dr. Zito, Mitra; (Middle) IJ Central Line Lab; (R) Dr. Bruttig, Dr. Henderson, and Dr. Hasenkrug

Bottom: (L) Dr. Gochoco, Dr. Sumpter, and Me; (R) Sam, Olivia, Me, Mitra, Roobi, Dr. Truong, and Dr. Jahnny!

Kingman Regional Medical Center

March 2021

Week 27: February 28 - March 6

two-thousand-and-twenty-one

The Highs:

Road-tripping with my mom
Started my EM Rotation in Kingman, AZ!!!
Central Lines, Trauma, and Fun times!
Intubation lab!
The FOOD.

The Lows:

The weather on the drive!
Couldn't get the vein on the central line

Overall rating of the week: 9.5/10

I’m finally starting my long-awaited Emergency Medicine rotation at Kingman Regional Medical Center in Kingman, Arizona!! I’ll be doing this rotation with another fellow student, Mitra, and several other students from surrounding schools. Some are doing this rotation as an elective/core, and others are doing it because they’re actually interested in EM (like me!)

My awesome mom flew in on Friday afternoon and I picked her up from DIA. We met Michael at Sushi Den in Denver for dinner- which is this super fancy Japanese sushi restaurant that had the neatest aesthetic... we had to take an elevator to the dining room, and there was live bamboo inside of the restaurant that scaled the walls! The sushi was also pretty good – we ordered a nigiri platter and a sashimi platter. What was surprising though was that as good as it was, it had the same quality of fish that my dad serves in our restaurant back home. I was insanely proud that my parents’ small, family-owned restaurant could compete with such a high-class restaurant such as this.

After a filling dinner, my mom and I drove back to Greeley to finish packing and get ready for our drive to Arizona. We got up around 3am, and left close to 5. We had hoped to take the route that led us down to New Mexico so we could avoid going up to the mountains, but right as the 25 diverged into separate highways, my Carplay disconnected and I lost GPS. I ended up just following the 76 for some reason, and when I got my GPS back on, it didn’t show that we were taking the mountain pass, so I thought we were okay. An hour or two later, I realized my mistake because we were headed towards Vail... and it was starting to snow, and the roads were awful. I literally thought I was going to break down because I was so scared to drive through these road conditions. They were worse than when Hannah and I were driving home from Aspen. I could barely see in front of our car, and the fog made it impossible to tell if we were even in the correct lane. We drove exceedingly slow, but thankfully, we made it out. From then on, the drive wasn’t so bad, and we saw gorgeous mountains and scenery without having to worry about an icy demise.

We finally arrived to my Air BnB in Kingman close to 10pm at night. We initially couldn’t find the right house because my GPS didn’t pin the right location, and so we were walking up and down the street trying to find house numbers with no avail. I contacted Renee, the owner of the house, and she directed us to walk all the way up to the corner house. With a huge sigh of relief, we arrived. Upon first entering the house, I was taken aback by the smell of incense, the shrine set up with a photo of a yogi on the wall, and a huge salt lamp. We quickly and quietly found my room, which was a small one-bedroom space with an open closet, dresser, and TV. We saw written directions on a white board, telling us that quiet hours were from 9pm-9am, so we whispered as we brought in all of my luggage and my cat, Millie. Even though we felt gross and sticky, we weren’t sure if it was allowed to shower so late at night, and so just changed into clean PJs, brushed our teeth, and quickly went to sleep.

On Sunday, we woke up early to shower and get dressed, because we were going to Vegas, baby! My mom and I drove 1.5 hours to the city of lights, and arrived at the Bellagio a little before 11am for early lunch and some fun. We walked away with no winnings, haha, but definitely had a good time. We then drove to the McCarran International Airport, and sat in the parking lot while we zoomed into Michael’s sister’s baby shower. So fun!! The games were definitely competitive, and my mom actually technically won, but I had fudged her numbers because I thought she bet too small.

Anyway, the next day I had both orientation at the hospital as well as my first shift from 10am-6pm. I got to meet all the other students I’d be rotating with at orientation, and was slightly surprised that only a handful of them were 3rd years. The majority were fourth year students who were expecting to find out their match results during this rotation! Wild!

After orientation, I arrived to my first ED shift with Dr. Chelsea Weisner, a 2nd year resident. She was a spunky, blonde-haired, blue-eyed doc who ran the ED like it was no body’s business. She was so badass! During my shift, we saw a 93-year-old gentleman who was brough in by ambulance with a temperature of 92F, hypotensive, and severely bradycardic in the high 30s. We ended up needing to place a central line in him because we couldn’t get venous access, and we needed to warm him up with warmed IVF. What’s crazy is that before this patient came in, Dr. Weisner showed me around the ED supply closet and was pointing out all the kits and supplies we needed for the central line. Dr. Snodgrass (RVU grad, and first year intern) was nice enough to show me how to set up the central line kit, and when it was time to place the femoral line, Dr. Weisner let me take the lead. I was so nervous because I had only verbally walked through this procedure ONCE with Dr. Webster on my last rotation, and I’d never actually done one. Using the ultrasound, I identified the femoral artery and the femoral vein, but unfortunately, when I inserted my needle, I ended up puncturing the artery. We pulled out right away and Dr. Weisner calmly said, “remember what we do when we get an artery? We just put pressure!” So we held pressure for about a minute, then she took over. It was slightly embarrassing because Mitra and Henry (4th year student) were watching, but since it was my first time, I tried not to sweat it so much. Just need to practice more!

On Wednesday, we had our first in-person lab, which was all about intubation! Dr. Justina Truong, Clerkship Director, was so nice to bring the intubation mannequin and a bag of supplies to the hospital. All the students who attended had the opportunity to intubate and receive direct feedback from Dr. Truong, Dr. Snodgrass, or Dr. Weech. So fun! I was also grateful to Dr. Weisner again because we went over intubation drugs on my first shift on Monday. Later that day, I had my second shift with Dr. Logan Bruttig (another 2nd year!). Two major traumas came in, one of which I was actually there for and got to witness the entire thing. Prior to this patient arriving, Dr. Sergeant (the attending physician) told me that I would be in charge of place the Intraosseous line if the patient needed one. An IO!? I’d never done one of those either. Then, a 50-something year old man came in by ambulance after sustaining a gunshot wound to the left chest. He was still breathing, his vitals were remarkably stable besides some tachycardia and hypertension. I got to watch Dr. Bruttig and Dr. Eric Batory (3rd year resident) do a primary survey on this patient, and then place a chest tube. The patient already had two large bore peripheral IVs placed, so he didn’t need the IO. Once imaging was completed and it was confirmed the patient did NOT have a pneumothorax, we were able to see that he was bleeding into his abdominal cavity and that the bullet had clipped his right liver and kidney. He needed to be transferred immediately to a tertiary facility, so once his secondary survey was complete, he left our trauma room. At that point, it was late into my shift, and midnight came sooner than expected. I left the hospital starving, so picked up some InNOut on my way home. Ahh, InNOut! It had been way too long.

The next morning during Thursday didactics, I heard from Dr. Batory that another gunshot wound patient came in. --A little back story, apparently patient #1 was going to visit his Godfather, then saw that someone was lurking in front of his house with a gun. The perpetrator shot patient #1, but was intending to murder the Godfather. Once patient #1 was shot, the Godfather came outside to see the commotion, then HE got shot. So patient #2 was the Godfather. Crazy!!

Anyway, my next shift isn’t until Sunday, so that wraps it up for this week!

But MAN, what a crazy first week of ED patients! I’m absolutely LOVING it, and so excited to be here.

Newest 3rd Year Medical Student at Kingman RMC!

3-1-2021

Week 26: February 21 - 27

two-thousand-and-twenty-one

The Highs:

Got to work with Dr. Gray and Dr. Burckart!
Great learning with Dr. Gray and practicing traditional IM
Scrubbed in on an Ortho case!
Reencounter with Steve
A wonderful exit interview from Dr. Moore

The Lows:

Last week in Sterling

Overall rating of the week: 8.5/10

This was my last week of Internal Medicine at Sterling RMC. Oh my gosh, to say that I've learned a lot and grown as a student is an understatement. This rotation has pushed, pulled, molded, melted, and re-molded me in more ways than I can count! What I can say is that I know I'm on the right path, and I know I'm cut out to be here. (What a flipping amazing feeling, too!)

I got to work with Dr. Jamie Gray and Dr. Kimberlee Burckart this week, which was really fun! Dr. Gray practices traditional Internal Medicine, meaning she likes to have morning rounds with the entire team (pharm rep, the nurse manager, residents, students, and her) and she likes to have Dr. Burckart and I present our patients to her and we all talk about the care and management so everyone is on the same page. It's actually a fantastic way to get work done, and I really enjoyed the flow every morning. We'd have sign out, then pick our patients for the day, and then at 10am, we're ready to round, see our patients again, and discuss their care.

I also had a list of topics that I gave to Dr. Gray that I wanted to discuss about this week - it included DKA, Stroke management, AKI, and Asthma. She seemed impressed that I approached her with objectives for my own self-directed learning, and throughout the week, we spent some time talking about each topic (except for Asthma because we ran out of time!). Initially she came on last Friday, and Dr. Webster and I stayed late since we had two admissions right around 6:30pm. He took one and I took the other. The patient I admitted was an 80-something year old male with acute pancreatitis. I thought this was going to be a simple case, but his CT scan showed possible pancreatic abscess vs necrosis and he initially met SIRS criteria! We started him on fluids and IV antibiotics that evening, and he ended up staying in the hospital for several days due to the pain and slow process of advancing his diet. He was married to a Filipina woman and had a 14 year old daughter. During one of our many conversations, I asked him how he met his wife. He said he travelled to the Philippines and she was the one to help him navigate the island and understand the language. They fell in love and got married. He still loves her, but she fell out of love with him. It was a really sad story, and made me a little upset. When she brought their daughter to visit him in the hospital, some harsh words were exchanged between them, and on his day of discharge, she unfortunately refused to be there to pick him up. A friend took him home. I don't know why that made me feel so sad... maybe it was because I could see his pain, and he also seemed very genuine when talking about how he still loved his wife. That hurts...but as a medical student and future physician, I know it's not my place to sympathize with every patient I come across. If I dwell on it too much, it becomes emotionally taxing to me, and I have to set up my own boundaries to protect myself. Still though, I wish the best for him and hope he finds happiness and health.

Later in the week, we actually air lifted two patients off the floor! One was a patient who was a direct admission from down in the Family Clinic. Dr. Webster called Dr. Burckart saying he needed to admit a patient who was showing signs concerning for sepsis. She was actually a patient that was admitted the week prior for COVID and respiratory symptoms. Dr. Burckart was wondering whether the patient needed to be stabilized in the ED first before coming up to the floor, but due to the insistence of Dr. Webster, just admitted her to the medicine service. We were lucky that we were "slow" that day and had enough staff, because this poor woman was very ill. Her bedside echo showed an EF of 15%, and we ended up needing to fly her NCMC for cardiac interventions. However, the patient was unable to make any decisions for herself, and kept changing her mind saying she wanted to die, so even though we did the right thing, she ended up refusing help. I'm not sure if she's still alive or not.

The second patient was one that was admitted by Dr. Gray in the wee hours of the morning. The overnight nurses said she got pretty delirious overnight, and was acting very strange, but not abnormal for delirium. Using her gut feeling, Dr. Gray ordered a CT scan of her head. Dr. Burckart and I went in and saw the patient who was completely lucid, talking, behaving appropriately, and was AxO x4. She was admitted for a UTI and dehydration. However, her CT head came back showing a massing cerebellar bleed. Two days in a row, we air-lifted a patient to NCMC, this time because our hospital did not have neurosurgery. She was re-scanned as soon as she landed, and was then sent straight to surgery for removal of the hemorrhage and clot. What was so crazy was that her neuro exam was essentially benign! She showed no focal deficits, and her cerebellar tests were all negative. The only thing we didn't check was her gait. Also, we decided to Foley cath her for her trip to NCMC. Upon looking at her vagina, we noticed she had severe lichen sclerosus, and it was difficult to find her urethra. We did manage to insert the cath though, and off she went.

Also this week, we had a very interesting patient come through. He was a convict at the maximum security prison, who required two fully equipped prison guards with him at all times, and was chained and handcuffed to the bed. He was admitted for a severe bursitis requiring IV antibiotics. It was the LARGEST soft tissue/bursitis infection that Dr. Gray, Dr. Burckart, and I had ever seen! His entire forearm was indurated and angry, but he still maintained mobility of his elbow joint, which reassured us the infection hadn't spread to his bones or actual joint space. He apparently fell while cleaning a couple of weeks ago and scraped his arm. A scab formed, which he picked off. Then the infection started. At the prison, they gave him oral Keflex, but it wasn't enough to treat the infection so it got progressively worse. He was being seen by the orthopedic surgeon, Dr. Fenton, and us for medical management. Dr. Fenton invited Dr. Burckart and I to come and help with the Incision and Drainage in the OR, so one day after lunch, we geared up and scrubbed in! It was SO awesome!! Dr. Fenton basically let Dr. Burckart and I do the entire procedure; it was mostly Dr. B, but I was first assist for sure. I had my hand inside of his arm, breaking up the septations that had formed, and washing out all the bacteria. Surprisingly, not a lot of pus came out, and it wasn't as smelly as we thought it was going to be... I guess that's a good thing, haha. Anyway, both Dr. B and I got to place a few sutures to close his incision, and then we packed it with almost 3 feet of iodoform gauze. The next day after surgery, we removed the packing and replaced it because we saw it was covered in bacteria. The IV antibiotics were still being given, and we continued to manage him appropriately. But like dang! The antibiotics were definitely working, since his infection was going down nicely.

On Thursday, I planned to work a 24 hour shift. I finished with Dr. Burckart around 7pm, who by the way, was SO great to work with during the week! She showed me that even as a resident, we're still learning, making mistakes, and fixing them. She has this amazing gut instinct about things, but is working on following that instinct. I think also she struggles with standing up for herself, but has no problem advocating for her patients. It's very interesting to watch. But I have SUCH high hopes for her. She's so smart, is very passionate about OB, and is going to make a phenomenal physician. She has a major job interview coming up at a well-renown facility, and I'm praying SO hard for her!

Anyway, that evening, as I was watching the ED board for possible admissions, I saw a familiar name: Steve. My heart sunk to the pit of my stomach. Oh no, why was he here so soon after being discharged? Was he okay? When I had a spare moment, I went down to the ED to see him. I popped my head into his room, and he immediately smiled at me and welcomed me in. He said he was wondering about me since he was discharged, and was glad to see me. I learned that he had bloodwork done after he left the hospital and his potassium was 7! That was an extremely high value, one that could potentially kill him, but he was here talking and laughing like nothing was wrong. He said that day he was going to try to go back to swimming but ended up not being able to because of his lab results. It's so strange... sometimes you meet people, and you wonder if you met them for a reason. Twice now our paths have crossed and we've felt this instantaneous connection, and we both thought about each other and wondered how the other was doing. Me because he reminds me of my dad. Him because... well I'm not really sure. But it made me wonder. Did I meet him for a reason? Will our paths eventually cross again, and do we have some kind of good fated or destined relationship? Maybe, and this is crazy, but maybe he was someone I knew in a past life. Or maybe he’s someone I’ll know in a future life. But now we’ve met, and I don’t think I’ll ever forget him and his face, and those kind eyes, and that soft smile.

After I made sure he was okay, I went back upstairs to do some more work. Then Dr. Webster texts me and asks if I can come back down to the ED because Steve really wants me to meet his daughter. So I did. I met his daughter Laurel, who's beautiful and she's going to grad school this fall to become a social worker. When he was discharged, we shared a hug, and parted ways again, but I wish him the best. And who knows... maybe he's someone I'm supposed to know. I'm not sure.

Also on Thursday, I had my exit interview with Melissa and Dr. Moore. I received nothing but great feedback from them, saying that no one who worked with me had any negative things to say or advice to improve. As awesome as that is, and as great as it is to know I did well on this rotation, it also makes me wonder when I'll find another Dr. Wang to point out how I can improve. Hoping it won't be too long now!

So long, Sterling. You were amazing. All the people were fantastic. And I'm really, really going to miss it. If I were going into family medicine, you'd for sure be a top choice.

Left: Cindy, the wonderful woman who let me stay in her apartment while on rotation, and Me

Middle: Dr. Gray, Me, and Dr. Burckart!

Right: Me and Lynn, the kindest, best social worker!

Sterling RMC, 2-25 & 2-26-2021

Week 25: February 14 - 20

two-thousand-and-twenty-one

The Highs:

Got to work with Dr. Wang and Dr. Webster!
Improving my presentation skills
Central Line and Ultrasound practice!
Meeting Steve
My little stint in the ED
Rural EM Practical Conference!
Maybe securing an FM/Global Med elective... in Hawaii!

The Lows:

So tired all the time!
Side effects from the second COVID vaccine and sort of freaking out about it.

Overall rating of the week: 9/10

I finally have a second to update! This week was one of the best on my IM rotation. I got to work with the power duo of Dr. Eric Wang and Dr. Eric Webster, who were both just so awesome. I learned quite a bit this week because Dr. Webster loves teaching, and the moments that I got with Dr. Wang were especially beneficial. Initially I wasn't sure how to feel about Dr. Wang since he gave me major introvert vibes. However, after a couple of days of working with him, I was surprised when he chose a couple of patients for me to follow and see each day, stating that those were better cases for my learning. I was like, wait hold up! All this time I thought you didn't really like me, but it turns out you do! After that, he was very quick to give me feedback on my oral presentations, the first time I had ever gotten feedback on them from a preceptor. He helped me improve the structure of my presentation, bringing to my attention that when I'm delivering the Objective part, I need to STAY objective! It was the most obvious piece of feedback, but one that I really needed to hear. From that moment on, I worked hard to keep the SOAP structure -- which was actually a struggle for me. I kept having to actively tell myself NOT to state my interpretation of the labs/EKG/Physical exam, and just be as blunt and direct as possible. Dr. Wang also didn't seem to like it whenever I said, "Consider changing the patient's med," or "Consider adding this to the regimen". He'd always follow it up with, "Have you considered it?" and I'd say, "Yes, we should change the patient's med." Then he'd smile a little bit and we'd move on.

There was a specific patient I remember having, because he's one I'm not going to forget for awhile. His was Steve, and he was admitted because he had hypertensive emergency, flash pulmonary edema, and a severe CHF exacerbation. He was just the nicest patient, and had a daughter a couple of years younger than me. When he came upstairs that evening with his daughter, Dr. Webster asked him about his code status. Turns out he fibbed to us that he was a full code because he could see that his daughter was really uncomfortable and scared. The next morning, when I saw him at bedside and asked him again alone, he changed his code status to DNR/DNI. This hit me pretty hard because Steve is my dad's name. And the patient Steve and my dad both have birthdays in the same month of 1945. And my dad has told me multiple times that if the time comes where he's going to die, just let him die. Every time he tells me that, I get angry and try to convince him out of it, but he's stubborn. However, if my dad were ever admitted, and I was there with him, I wouldn't want my presence to affect his decision on whether he wants resuscitation or not. I would want him to be honest and to choose what he wants, because so many times in his lifetime, he didn't get to choose his path. At least in death, he should be able to make that decision himself, regardless of what I want him to do. My feelings are selfish because if anything were to happen to my dad, I'd be absolutely destroyed. I can't imagine him not being here, and it hits me every time something like this happens. *deep breaths. Anyway, Steve was a gem. Dr. Wang put in the time to teach me how to find a JVD and measure a JVP on Steve. Dr. Webster let me talk to him and help him fill out a MOST form, which basically decides how much intervention you want if you become really sick. And when Steve was discharged, my heart soared because I was so happy for him. He had those kind eyes that just made you feel warm. I wished the best for him when he walked out of the hospital.

The rest of my week working with Dr. Webster was just amazing. We got along really well, laughed often, and learned a lot! He always took the time to explain things to me, gently pimp me, and answer any questions I had. He's also really great at reading EKGs, and we spent some time going over basic EKG reading to prepare me for my EM rotation next month. At the beginning of the week, I told him 4 topics that I wanted to discuss throughout the week - Sepsis, CHF, Central Lines, and Ultrasound. We covered them all! Dr. Wang was awesome in joining in our conversation about CHF and the types of heart failure, and again, I felt so grateful that he was taking the time to teach and make me a better doctor. On one of the slower days when Tim the PA was with us, Dr. Webster brought in his practice central line kit, and explained how to set up the kit and place the line from start to finish. He also let Tim and I practice the FAST exam on him, and let us look at his IJ with the ultrasound.

We also had a couple of things down in the ED that we saw - such as blisters on a patient after experiencing frostbite, which Dr. Webster let me poke, drain, clean, and wrap. Then, one day, the ED was so busy, so we decided to go down and help out! I got to see a patient who arrived complaining of LUQ/L rib pain that started after bending sideways to reach for something. I got to present to the attending ED physician and come up with a plan for her. When he asked me what I wanted to do for pain, I said I'd give her a shot of Toradol. He was like, you know, that's a really great idea! I was going to give her Norco, but Toradol is better! Even though it was a straight-forward case, I felt exhilarated down there, and was so happy to be able to help.

In other exciting news, Dr. Webster signed a contract for a job once he finishes residency this year... on the Big Island in Hawaii! He'll be working with a lot of the indigenous Samoans and other locals in a small Family Medicine Clinic. I asked him if he's willing to take students, and he said yes! I then asked if I could try to set up a rotation with him next year, and he was more than happy to do that too! Hoping I can do that for my Global Medicine rotation, and get to visit Hawaii for the first time!

Oh! Let me tell you about Maria. She was my fifty-something year old patient with developmental delay who got admitted the week prior for bad bilateral cellulitis and osteomyelitis of her right leg. She was such a character, but I did my best to connect with her and make her feel comfortable, which is why I think I got along with her so well. Anytime she was scared, I'd bring out my phone and play her some Johnny Cash, her favorite singer. We'd practice the alphabet in sign language together, and talk about her love for Solitaire. She was kind of harsh to everyone, but I'd like to think she tried to be kinder when I was around. I stayed with her and the PICC nurse when she was getting her line placed, and that really helped with the process. Sometimes Maria can retaliate and be difficult to work with because of her pain and her dislike of being uncomfortable. However, if I can distract her with little things, then the entire process becomes better. She had the biggest crush on the food services guy, Joey, and would get so excited on days he was working. It was heartwarming to see, and Joey was always so nice to her.

On Saturday, I got to participate in the Rural EM Practice Conference! It was held virtually and they mailed out kits to all the participants so we could get some hands-on practice at home. The morning was full of presentations about things like Stroke and how to recognize Child Abuse, and the afternoon was the Procedure course. Everyone got to rotate through different virtual rooms and practice the horizontal and vertical mattress suture, talk about airway management, practice intubation and a cricothyrotomy, and learn how to make a push-dose of Epinephrine. Super fun and creative! We used ketchup packets to simulate blood in the cric lab-- kind of smelly and messy for a DIY lab, but I guess the real thing is also smelly and messy too! Haha.

Lastly, I guess I'll talk a little more about the side effects I got from my 2nd Moderna COVID vaccine last week. On Monday when I got home, I had the weirdest new aura for my migraines. I was watching some Online Med Ed on the TV with subtitles on, and suddenly half of the words vanished from my vision. This wasn't new, but I was like, oh man, am I going to have a migraine right now? And THEN, I lost all of my peripheral vision on the left side only. I started to freak out thinking I was having a stroke because I had no headache yet... I was on the phone with Hannah telling her about my symptoms and what should I do, but then my aura started to resolve, and then BAM! The migraine came. I was incapacitated for the rest of the evening, and had to lay down and go to bed extra early after taking lots of pain meds. I woke up in the morning with the migraine, so I popped a couple of Excedrins and dragged my feet into the hospital. Luckily the medicine started to work and my migraine resolved. However, I started to have some stomach pain! Every time I drank water or ate anything, my stomach would start to throb and ache. I was fine when I wasn't eating, but man, it was an uncomfortable feeling. This lasted for a few days before resolving by the end of the week. I was scared though that I wouldn't be able to eat normally again, which would absolutely suck since I love to eat. Haha. After the stomach pains went away, I was completely normal and healthy again. Would I recommend the vaccine? 11/10 yes. Do the side effects stink? 11/10 yes. But is it worth it? 11000000/10 yes.

Some final remarks about this week - like I mentioned before, I was initially nervous about working with Dr. Wang because I thought he was kind of quiet and introverted. Even if those things might be true, what I discovered was how much he truly cared about my learning and giving me a great experience. I like to think the first couple of days he was just observing how I worked, reading my notes, and listening to my patient presentations. Then, I think once he got a handle of where I was at, he took the time to point out what I could work on, and provided me with excellent feedback. Sometimes receiving negative feedback doesn't always make you feel good, but if all feedback was positive and spoon-fed carefully to you, I think you wouldn't learn how to handle criticism, and your head would just get massively big. (lol). His feedback showed me that he payed attention to where I was lacking, and instead of letting me continue down that path, TOLD ME, and gave me the opportunity to fix it. That's a doctor who cares. That's a doctor who for sure, I know wants to make me better. That's a doctor who I'm going to remember and try to emulate in the future. Don't take negative criticism personally - it's an opportunity for you to grow and change. And I'm so grateful that he said something to me.

Dr. Wang, Me, and Dr. Webster!

Sterling RMC, 2-19-2021

Practicing Intubation with a Bougie and my DIY Trachea for the Rural EM Practice Conference!

2-20-2021

Week 24: February 7 - 13

two-thousand-and-twenty-one

The Highs:

Worked with Dr. Bresnahan and Dr. Bowell!
Started an IV!
Helped manually disimpact someone - yes, this was a high, lol.
Witnessed seizure-like activity
Worked with Dr. Hillis!
Saw a coding patient
Got my second COVID vaccine!

The Lows:

About the same- behind in studying
Tired
Dealing with a patient's difficult family member
The coding patient died
COVID vaccine side effects... boo.

Overall rating of the week: 9.5/10

This WEEK! I said goodbye to Dr. Workman on Tuesday, and then was quickly introduced to Dr. Cassandra Bresnahan, who's this bubbly, passionate, firecracker of a physician that loves to do procedures! She's so eager to teach, see patients, and care for them. Her enthusiasm for medicine is palpable, and it's hard for it not to rub off on you too! I also had the honor of working with Dr. Erik Bowell this week, who's the resident that I delivered the placenta with last week! He was super nice and very willing to help and explain things to me. I felt like I got along really well with him all week!

Even though my time with Dr. Bresnahan was going to be short, I think I did my best to shine and work hard. The number of patients on the floor this week was significantly less than the amount I had with Dr. Workman, so the days had a little bit more downtime. On Wednesday, we had a new patient in the ICU who was in for recurrent DKA. She was actually transferred from Julesburg to our facility because she needed higher level care. Dr. Bresnahan, Bowell, and I rounded on her on Wednesday morning and I felt good that I was able to answer all of the questions I got asked about DKA and metabolic acidosis. Thursday, we went back to talk to this patient's husband, who revealed some shocking details to us about her drinking habits, past DUIs, and neglect in the care of their son. We all left a little rattled at the information we just learned, but again, this was all one sided from the husband, so we needed to wait until we could talk to the patient directly to see if the stories aligned. Of course we had our case manager and social worker on it though, and even reported to Child Protective Services because the 7 year old son was home for who knows how long in the day with his mom passed out on the couch. But alas, when Dr. Bowell talked to the patient, we found out that she hadn't been drinking, and that all of what her husband said was not true. There was definitely something fishy going on, but it wasn't truly our place to step in; we were responsible for her medical health; what happens at home is outside of our scope. She didn't meet criteria for a rehab center because she wasn't drinking and she also did not willingly want to go. *sigh, it's complicated.

Last week with Dr. Workman, we had so many cases of small bowel obstruction and hyponatremia. This week, it was syncope town. We basically had back to back admissions for patients with new onset syncope secondary to... ?. It was our job to work them up. One of the patients was an elderly gentleman who syncoped in front of his wife and had seizure-like activity. Despite a thorough work-up in the hospital, we couldn't find anything that would cause his syncope except for the fact that the day before it happened, he received his first dose of the COVID vaccine. This patient also had his first ever episode of syncope while he was battling COVID back in November. Coincidence? I'm sure they're related, but I just don't know how.

Anyway, I went in to talk to this patient about how he needs to follow up with his cardiologist. In the middle of me conversing with him and asking him who his cardiologist was, he said, "I feel like it's going to happen". I asked, what do you feel? But then his eyes rolled back, and he started to have seizure-like activity right in front of my eyes! His upper and lower extremities were shaking, he was moaning, and then he came to. It must have lasted 10 seconds or less. I looked at my watch for the time that it happened. It read 12:01pm. I saw a student nurse walk by the room, and called her in for help. He was completely lucid by that point, AxO x4, had a benign neuro exam, and denied any chest pain or SOB.

I quickly walked out to find Dr. Bowell, then remembered he went down for lunch. And of course no one was at the nurses station. I remembered he texted me the week prior, so I pulled out my phone and called him. He asked me to get a stat blood glucose and a new set of vitals. So I went back and with the help of the student nurse, got new vitals, and then found his actual nurse to do the blood glucose. Everything was normal. Luckily, this patient was on the tele, so we were able to actually go back to the exact time of the syncope to see if there was an arrhythmia or anything preceding the episode. That was normal too! Ultimately, the patient was discharged home that day, asked to follow up with his PCP and his cardiologist, and told he could not drive until we figured this out.

Once again though, I was surprised by how calm I was in that moment. I totally could have freaked out and called a code blue, but instead I waited for the seizure to pass, reassessed the patient, stayed with him the entire time, and acted rationally in a scary situation. Witnessing seizures is a terrifying thing... but actually, seizures are fairly benign. Even though I didn't learn that until afterwards, I was praised by Dr. Bresnahan for my quick actions and for staying calm. How gnarly though! I can still feel my heart pounding when I think of that memory.

As I was saying, this week was relatively "slower" in service than the last. So during my downtime, a nurse came around and asked if anyone wanted to start a line on a new patient. I was just typing up a progress note, but without even looking up, I raised my hand and said, "Oh! Me!" When I turned around, I realized she was asking the two nursing students if they wanted to do it. Embarrassed, I apologized. But, the two students were like, "No, you go on ahead! You're clearly more excited about it than we are!" So that's how I ended up putting in an IV on my lovely patient, MM. She was a 53 y/o F with a history of developmental delay, who was there as a direct admission because she had two lower extremity ulcers that were draining purulent discharge. I got her IV in on my second try. Success!

Shortly afterwards, the same nurse, Danielle, asked me if I wanted to help her disimpact another patient. So I said sure, put me to work! I think that there's no job that's too low or dirty for me to do. Everyone's occupation is important, and if there's anything that I can do to help, then I'm there. This elderly female patient was admitted for a UTI and weakness earlier in the week; the daughter of the patient also had lung cancer, and was having trouble taking care of mom with her granddaughter. She was admitted and could have been discharged in a day, but we were being nice to help out the family. This was also the patient who was the epitome of one of Dr. Workman's unanswerable questions! Anyway, she was majorly constipated, and after multiple enemas and bowel regimens, she still was failing to empty her rectum. So I went in there and helped manually disimpact her. It was actually a very humbling and rewarding experience, both for me and the patient! I was glad that I could be the one to provide her some relief, and boy, was she constipated! After the first round of disimpacting, I came out of her room and threw my fingers up in victory. The nurses and Lisa, the PT, all laughed. When my patient was ready to try again, I went back in and disimpacted her some more. She was so thankful towards me, and as literally dirty as the job was, I felt happy that I was able to help her.

Dr. Bowell was pretty impressed that I went in to do that. I literally have no fear, and that makes me feel confident that I'm doing some good here.

Later that day, I went down to the ED to help admit a patient, only to find out he already was taken upstairs. But, there was a new patient who was going to be admitted, so I was going to get to talk to that one and get him started. Dr. Hillis was working, and she's such a rockstar I just love her. She's incredibly nice, and is very open to teaching! She pulled out some EKGs and I got to go through them with her, and she also encouraged me to talk to the patients in the ED. She was working until 8pm that evening, and said if I can get off early, to come down and finish her shift with her. Amaaaazing!

Anyway, I went in to talk to this elderly gentleman, who was in because of stroke-like symptoms. He was found passed out on the floor that morning by his wife, and was very confused, couldn't process correctly, and was slow understand commands. I probably shouldn't have asked so many questions getting my full HPI, because it was clear that the patient was struggling to recall his story, to the point that the wife interjected between each question to correct the information. I could tell she was getting annoyed, and tried to dispel the anger by apologizing and saying that I understand they've told this story several times today, but it was important for me to ask again to expedite the admission process. During my physical exam, I was listening to heart and lungs and heard wheezes on the left side of the chest. I proceeded to ask whether the patient had a history of asthma or COPD. Then, out of nowhere, the wife completely snapped at me and said I wasn't allowed to ask him any more questions, can't I tell that I'm fatiguing him?! She told me to leave immediately. I started to apologize, and she yelled at me, "No, you are not a doctor, and you are not even a nurse. You are just a student! Get OUT!". I tried again and said I just had a couple more questions to ask, and I understand her frustration, but she said, "No, if you understand, then just LEAVE!" So I said okay, I'm sorry, and I left the room. I was totally rattled, felt so bad that I caused her to get upset with me, and scared that I got yelled at like that from a stranger. But then I also thought, she must be scared too, and she's probably worried, and emotional, and everything she said was true- I'm not a doctor, and I'm not a nurse. So why does her husband have to be a part of my learning experience? Still, I felt really bad, and went back upstairs with my head hung low.

I told Dr. Bowell and Dr. Bresnahan what happened, and we all agreed that once he comes up, we'll go in together and finish the neuro exam that I didn't get to do, and ask about his code status, which I also didn't get to do. But this time, I geared up, because there was no way I was going to leave the hospital without making things right and clearing the air between me and the patient's wife. After Dr. Bresnahan and Dr. Bowell left the room, I stayed behind and reapologized to the wife. I told her that I would use it as a learning experience to consider how the patient and his family feels, especially in such a stressful situation. I was really sorry for causing her distress, that wasn't my intent, and I hoped we could work together in the upcoming days since I was going to be apart of his care. The wife had calmed down quite a bit, and she also apologized to me, explaining that she was stressed and just lost it, and took it out on me. We were fine, and that was that. I felt SO much better, and when I left the room, Dr. Bresnahan and Dr. Bowell were waiting for me, and were just so stunned that I went back into the room. I just did what I thought anyone else would do in that situation, and tried to be extra understanding and empathetic. It turned out to be a good thing though, because I heard later that it really impressed Dr. Bresnahan.

That was basically the end of my IM shift, so around 7:30, I went back down to the ED to meet Dr. Hillis again. She was just wrapping up her shift, and Dr. Ashar was coming on. But Dr. Hillis asked for my phone number and email address so she could connect me to one of her friends who's the PD at a program in San Antonio, TX! Once I said goodnight and went back upstairs to grab my backpack, she texted me saying a code was coming in! So I rushed back down to the ED with my stuff, and got ready with the team to accept this incoming patient.

It was going to Dr. Ashar since Dr. Hillis was going home, but she stayed behind to orient me to their ED, and helped prepare intubation tubes, the bougie, the glidescope, and other instruments that Dr. Ashar might need. We talked about induction meds - Etomidate and Succinylcholine being their go-tos, and needing to be prepared for anything. The patient was brought in by EMS with vomit all over his face and body. He was passed out at home, and started to vomit en route to the ED. The vitals were all over the place; the patient was hypoxic, tachycardic, and his BP was high. Dr. Ashar attempted to intubate, but the patient vomited shortly after the tube went down. The end-tidal CO2 reader changed color, but because of the vomit and because we thought we heard air in the stomach, we pulled the tube out and tried again. Unfortunately, after many attempts, the airway was never established. The patient kept aspirating and vomiting, and CPR was started. I was asked to run and get more ET tubes because they ran out of size 7, 7.5, and 8. I was asked to prepare the epinephrine push, and basically assisted in doing whatever I could to help the nurses. The patient achieved ROSC once, and even the EMS fireman attempted intubation multiple times. He never made it back. He was only 38. His tox screen was positive for Ecstasy, Meth, and Marijuana. When we talked to his wife, she was shocked because he was attempting to de-tox and had a job interview that morning. She couldn't believe he was gone.

Hannah and I have talked about this before, how vomiting is such a visceral reaction - the entire body convulses to expel whatever contents were left in the stomach. It's one of the most animalistic things a human can do. When I was watching this patient repeatedly vomit dark brown bile over himself and our staff multiple times, I didn't dare look away. I didn't let myself react. I just kept focus on what I was doing and how I could help the team. In those moments, I feel most alive. There's a patient dying in front of me, but I don't focus on that. I focus on what I can do to help. And I think that's why I'm excited to pursue a career in EM. Again, I just wanted to be the person doing it. I almost volunteered to try intubating myself. But there's no way they'd let me, I think. Also, if both the doc and the EMS person couldn't get the airway, what luck would I have? Probably little to none. Anyway, it was another great experience for me to watch and see what went wrong, and what went right. Dr. Hillis texted me about it the next day, asking how the patient did. I told her he died because we weren't able to get the airway. She then used it as a teaching moment to tell me that the success rate for intubation decreases after every attempt. And also proceeded to let me know how she might have handled the situation differently. Man, I wish I could work under her one day... maybe I can come back to Sterling and do an elective rotation with her next year.... we'll see.

Friday, I was just doing a half day. I made it my goal to see that stroke patient again, and wrote up his progress note. I also continued to see MM, who was going in for surgery that day to irrigate and debride her leg ulcers. Once I finished up, I was able to say goodbye to Dr. Bresnahan and Dr. Bowell, and went home to pack for my weekend back in Greeley. I was going to get my second COVID vaccine on Saturday, and was also excited to see Michael, Hannah, and my cat Millie. I got home on Friday afternoon and had a wonderful evening catching up with Hannah, playing with Millie, and relaxing with Michael. We watched a few episodes of Cobra Kai, and had Chipotle for dinner... one thing about Sterling - there's no Chipotle/Qdoba out here! I was craving that like no other. Haha.

Saturday, I got my vaccine! Yay for medicine! But oh man, the side effects were disastrous. I immediately felt arm soreness, and at night, I got the chills and spiked a 103F fever despite taking 600mg Ibuprofen before going to bed. Sunday I woke up with terrible body aches and fatigue, but still ended up having to drive back to Sterling.

Overall though, it was an awesome week, I learned so much, and I really felt like I integrated myself into the team at SRMC. Next week I'll be working with Dr. Wang and Dr. Webster, and have heard great things about them too! So far, I've been loving my rotation at Sterling RMC. It's been the most rewarding, most hands-on, most tiring experience (lol), and I'm so grateful to be here.

Dr. Bowell, Me, and Dr. Bresnahan!

Sterling RMC, 2-12-2021

Week 23: January 31-February 6

two-thousand-and-twenty-one

The Highs:

Started my first IM rotation in Sterling, CO at SRMC
Meeting Dr. Casey Weiser, PGY-II
Becoming a student of Dr. Frederick Workman
Delivering my first placenta!
Discovering how I work under pressure
Catching up with none other than Dr. AC Hernandez!

The Lows:

My patient died.
Sink or swim, Liz!
Exhausted
Behind in studying

Overall rating of the week: 9/10

So much happened this week, it's going to be a long post! I moved to Sterling, CO on Sunday in preparation to begin my next rotation: Internal Medicine at Sterling Regional Medical Center. I was pretty nervous about this rotation because I was going to be in a rural area where I didn't know anyone, and also I've just been intimidated by medicine in general. I think that's because it's so broad - in general IM, you can get patients with anything - from CHF, to pneumonia, to COVID, to small bowel obstructions. And you have to be prepared to manage them all at once! I kind of like to think of it as a busy ER and you're juggling 8-9 patients at the same time. The biggest difference is with IM, you treat and micromanage all of the patient's medical problems, and you see them every day until they're healthy enough to go home. In EM, you are literally triaging each patient, deciding if they stay, go home, or get transferred, and you almost hyper-focus on the chief complaint that brought the patient to the hospital in the first place. Anyway, here's what happened this week:

On Monday, I arrived early to meet Melissa D., the residency program coordinator, who showed me where I was going to be, where to find hospital scrubs, and of course, where the cafeteria was. Haha. Most of all, she introduced me to Dr. Casey Weiser, PGY-2, the resident who was going to help me get situated and comfortable on this rotation. I spent the day practicing notes, admitting people, and also presented two patients to the attending physician, Dr. Bachurina.

Casey taught me an important lesson on Day 1: when admitting a patient to the floor, it's crucial to ask him/her about code status. Even if the patient is healthy and seems like he/she would want full resuscitation, it's important to ask what the patient would want if anything ominous should happen during their hospital stay. It's also imperative to explain these interventions (CPR, intubation/ventilation) in a manner that the patient will understand. No big words, no long sentences. Short, direct, to the point. Even though this seems like such an obvious part of taking care of patients, I was nervous because it was my first time in awhile asking people these questions. It got me thinking about my own dad, who has told me time after time that if anything happens to him, he does not want to be resuscitated. When it's personal, you feel more affected by that decision than when it's said by someone who you don't have a connection with. At my age, I know I'm lucky that both of my parents are still alive, especially since they had me when they were older. But also, I can't bear to think of my dad not being alive, or heaven forbid, if something happened to him while I was away, not being able to be there with him or say goodbye in time. Selfishly, I wanted him to live as long as possible, even if that meant he was hooked up to a machine. Thinking about his wishes now, I kind of understand why he wouldn't want to be resuscitated... more on this later.

Tuesday, I learned that I was going to be by myself for the rest of the week because the other resident who was working on medicine that week was taking time off for a family emergency. The attendings changed that day, and on came Dr. Frederick Workman, from Colorado Springs. I felt a little bad because I left the main area to go to the OB deck and help deliver a baby with Dr. Bowell, a third year resident! He came by earlier that morning and essentially asked me if I'd be interested in helping a patient who was in labor. I absolutely said yes, especially since I hadn't delivered any babies myself yet! I spent my lunch hour helping a young Chinese couple deliver their first son. The mother was struggling to get baby out, and it turns out that's because his hand was caught up by his face! We had to change the mom's position multiple times while also keeping a watchful eye on the baby's fetal heart tones. He really didn't like his mom lying on her left side, so for a good while, we tried pushing with her on her right. Finally, sometime after 1pm, the baby delivered! Dr. Bowell took the lead on it since the delivery was complicated, but he let me deliver her placenta on my own. I was able to perform a fundal massage for the first time, which took a lot more force than I was expecting! It was such a surreal feeling, getting to play a larger role in the birthing process for this young couple. I think for some people it's an ethereal experience. For me, while I was overwhelmed with happy emotions and ecstatic for this family, I still don't think it's something I would want to do for the rest of my career. However, that doesn't mean I'm not going to try to deliver as many babies as possible while in medical school!

After the delivery, I scrammed off to didactics until 4pm. Then, I finally got to meet Dr. Workman and sit and chat with him. We took a walk outside and sat down at a picnic table. We had a discussion about business, and how to run and maintain your business as a physician. He also asked me about myself, and gave me my first task: to find out about him and tell him about himself the following day. I was excited about this challenge, because I think it's a great way to get to know the people you're working with, especially when you're new. He also said he didn't mind if I stalked him on Facebook (lol), and he really pushed me to do what I could to find out about him. So when I got home that night, I stalked not only his Facebook, but his entire family's, and even managed to find his class of 1996 graduation pamphlet from medical school, which also had his class photo. From there, I found out his hometown, and was even able to find his parents' obituaries. This exercise taught me a couple of things: First, there's a TON you can find on the internet about someone if you know how to do a little digging, which is a scary thought, and two, maybe I should have become a private detective. Lol.

On Wednesday, I had the most telling, most incredible, yet devastating experience. My day was going along just fine, and a new patient was being admitted downstairs for a sacral fracture a few days ago with persistent R hip pain. I went to the ED to talk to this 87 year old woman, who was so sharp and mentally with it. She was able to tell me her story from start to finish, answer all my questions, and even tell me her medication list with all the doses. To end my patient interview, I asked her about code status, explaining to her the risks and benefits of it and what it entailed, just like Casey had taught me. She said that if there's a chance she could come back, she wanted us to try. Okay, she was a full code then. I performed my physical exam, thanked her, and said I would see her upstairs. Tony, the house supervisor, was already waiting for me to finish up so he could transport her. When she got into her room, she apparently stood up and went to the bathroom with the help from her nurse. Then, as she laid back in bed, she became unresponsive. I was out at the nurses station with Dr. Workman, and we were talking about Toradol, another one of my homework assignments, when the nurse rushed out and said that she needed him at bedside immediately. We went over and saw that my patient was lying in bed, breathing, had a heart rate, but wasn't responding to sternal rubs, and couldn't talk. I took my white coat off and put it down in preparation. We called the rapid response team. Alicia, the main manager of the floor, came in and evaluated her, and said we needed to start chest compressions. She had a faint pulse, but it was very thready, and we couldn't pick up a heart rate on the monitor. One of the nurses started the first round of compressions. Standing at bedside, I was counting for her, 1, 2, 3, 4...all the way to 30. Two breaths. 1, 2, 3, 4...30. Two breaths. When she got tired, I jumped right in. Elbows locked, I got right over her body, hands in the center of her nipple line, and compressed. Someone else started counting for me. Underneath my hands, I could feel the crunch of her ribs, heard the loud cracks as they popped and fractured. But I couldn't stop. 28, 29, 30. Two breaths. Compressions again. Dr. Workman left the room to talk to the family. It was me, a ton of nurses, and the RTs. Every two minutes, they either called for a pulse check or pushed Epi. When they checked pulses, they were looking at me. I had my hand on her femoral artery, and I would call out if I felt it or not. Alicia then asked what her story was, what was her code status, should we even be doing this? No one responded, but I was able to provide crucial information about her, what her past medical history was, what medications she was taking, and what her labs showed downstairs in the ED. No one else in the room knew this woman like I did. Eventually, we achieved ROSC. She came to, breathing on her own, and was conscious, but ice cold. We all stepped out and were planning to move her into the ICU while we had her stabilized. We were going to intubate her, and help her breathe.

But then, when we were right outside of the ICU room, she went down again. Chest compressions restarted. More Epi was pushed. I was counting and checking pulses. I felt totally in control of my body and knew exactly what I was doing. I was able to contribute and be a part of this team. I wasn't just in the way. In the end, we brought the family in to say goodbye. It was more than likely that this patient wouldn't ever fully recover from the CPR, and she kept coding without the epinephrine pushes. The entire time, I was stoic. But then when her 91 year old husband came in and sat next to her, I gave him her hand, and heard him say, "Please don't leave me. What am I going to do without you? I love you." And that's when it took everything in me not to cry and turn into a blubbery mess. We moved her into the ICU and stopped all interventions. We never got around to intubating her, so we were just feeling for pulses until they got weaker and weaker. When I couldn't feel anything anymore, Dr. Workman came into the room, listened for her heartbeat, and called it. 12:24pm.

As tough as this situation was, and as tough as it is to write about it now, I'm still incredibly proud of the way I reacted and kept myself together. More than ever, I feel strongly that I want to be the one there, doing whatever I can, to keep patients alive. I want to be the one talking to the family, helping them cope, and delivering news to them. I want to be the one overseeing the chest compressions, calling out the meds, and being able to tell the family we did everything we could.

It's the tough moments that define your growth and what kind of person you will become. The last three years, I have been working hard on building resilience, on offering others grace, on using my strength as an empath to connect to people to help them through the good and the bad. Deep down, I've been questioning whether or not Emergency Medicine would be a specialty that is going to play to my strengths, and provide me with enough engagement to keep my flighty heart interested, and to push my growth mindset that needs to be fed. Or, is it something I picked because I think it's what I want to do? After doing CPR for the first time on my patient, after knowing that in such a high stress situation I am one who will react by staying calm, I am more certain that EM is where I'm supposed to be.

I went through a roller coaster of emotions on Wednesday. After the dust settled, Dr. Workman and I went out to talk about what happened and to debrief. I told him that there were things that could have gone better. He helped and pointed out those things, such as taking the stool when it was offered to me to assist in CPR even though I felt like my body mechanics were okay; retrospectively, he was right, and I should always receive help when it's given/being offered. But overall, I felt good about what I did, I felt like I contributed, I felt like I did right by the patient and her wishes. That night, I got home late, and when I finally called Michael to tell him what happened, that's when I allowed myself to cry. And I cried not because of what I saw, what I did, or her death, but because of the heartfelt goodbye I witnessed between my patient and her husband. That was absolutely the saddest part.

The rest of the week went well. I met another sweet patient, Mrs. S, who was there for a COPD exacerbation + pneumonia + SIADH. She finally got to go home on Saturday after being in the hospital for 6 days. She was one that I took care of during the entire week, and we had a great relationship. I had another patient who was older, and she was pretty angry with us after the first night because she was in so much pain and didn't get her usual pain regimen. I was able to kneel down next to her at bedside, hold her hand, and make her feel better. I checked in on her multiple times a day after that, and even drew a picture to help explain to her about her congestive heart failure. It was honestly a beautiful moment when she told me she knew I was going to become a really great doctor, and she was so happy that I was helping to take care of her.

On Friday, I got to talk to Dr. AC Hernandez on the phone, an EM doc I used to scribe for before I started medical school. He was so chill, and I was so glad we found a time to catch up because I reached out to him in hopes that he could help me network with LAC+USC's EM residency program - my dream program. I think the conversation ended really well because he said he would reach out to his contact at LAC, and also said he'd be able to write me a letter in support of me doing a sub-internship there this fall. That would be an absolute DREAM if it happens. Just so blessed to know these people, and to have had this experience this week.

I also came into the hospital over the weekend to keep up with my patients and see if anyone new and interesting came in. We did have a really sick 33 year old woman come in - she came into the ED with a glucose <20, Lactate of 18.4, AST/ALT >2000, and Creatinine >4! She was seen the day before in the ED with completely normal labs, so what the heck happened?! Well, she had a perforated duodenum, that's what! She ended up having an ex-lap and her bowel was repaired, but she was in severe septic shock, hepatic shock, and acute renal failure. Apparently in surgery, 4L of purulent fluid was drained from her peritoneal cavity. We planned to transfer her, but because of the winter storm, the helicopter/plane couldn't fly, and the highway was shut down. She ended up being transferred though two days later when her labs weren't improving.

Anyway, I've had the privilege of working with Dr. Workman this week, and he's the absolute coolest. He's very chill and laid back, very business-oriented, but he provides great care and is a fantastic story-teller and teacher. We went through several of his "unanswerable" question exercises, and even though I definitely failed all of them, I'll never forget the lessons I learned. Turns out that one of the patients we saw actually was an unanswerable question in the flesh! When she was telling me her story about why she became hypoxic and her oxygen tank, the lightbulb went off and the connection I got to make was insane! Not going to write about the unanswerable questions out of respect for Dr. Workman and any of his future students -- you have to go through the exercise and be just as confused and lost as me! Haha. But again, that's how we, as students, grow and become better. And I think that's exactly why I loved working with Dr. Workman so much - because he invested in my growth, and because of him, I know I'm becoming better. I also just think it's so cool that he's the team physician for the US Ice Skating team! And he's met Michelle Kwan!

Dr. Workman and Me!

2-9-2021

Outside Sterling Regional Medical Center

2-1-2021

Week 22: January 24-30

two-thousand-and-twenty-one

The Highs:

Enjoying my rotation with Dr. Patty!
Seeing so many amazing kids in the clinic
Preparing for my next rotation in Sterling, CO

The Lows:

Ending my psychiatry rotation
Botching my psychiatric intake patient -- oops!

Overall rating of the week: 8/10

This was my last week with Dr. Patty and the wonderful team at Banner Clinic! I met so many beautiful people here - Maria, Laurie, Donna, Candice, Lorena, Dr. Smith, and Renee, just to name a few. They've all welcomed me with open arms, and were so kind to me over the last week. I was sadder than usual to go into my final week of this rotation, mostly because two weeks was such a short time! I really didn't want to say goodbye so soon.

I saw lots of patients this week, many who had depression, generalized anxiety disorder, ADHD, and Autism Spectrum Disorder/Asperger's. The one quality that tied them all together was resilience. Many of them have seen Dr. Patty for years -- they treat her like a close friend, and confide in her about their worries, fears, and problems. One thing I really love about Dr. Patty is how honest she is with her patients; she won't let something slide if she doesn't agree with how the person acted, how the person behaved or handled the situation they were put in. I think this is so important when working with children and adolescents who are still trying to discover themselves, their personalities, and their identities. They need someone to "groom" them into decent, socially intelligent humans. On the first day of my rotation, I asked Dr. Patty how she reels in her own emotions and keeps her ideas and beliefs in check when seeing patients whose beliefs differ from hers. She answered, "I don't!" She thinks it's important for the kids to understand whether their actions are good or bad, and how it makes other people besides themselves feel.

I learned so much from watching her interact with and counsel her patients... I think I myself got some therapy by listening to her. If I have the opportunity in the future to come back and complete a four-week rotation with her, I would love that. She's become one of my favorite preceptors because she embodies the type of physician I am striving to become, and she's also very aware of her surroundings and her time. She sticks up for her patients, advocates for them like no other by offering to talk with their parents if the cause of the patient's strife is due to the parents. She praises them, tells them she's so proud of them when they do something right or show that they've made progress in their lives. When acute things happen, like this week with our one autistic patient who resorted to self-harm using an instrument she found at home, Dr. Patty did not hesitate to move her schedule to see that patient and her mom on that day. Because of the close relationship that Dr. Patty established with this young girl, she knew exactly how to ask her questions in order to reveal vital information towards this case. Again, just in awe of Dr. Patty and her practice.

In terms of being aware of her time, Dr. Patty knows what she values, and even though she's very altruistic, she sets boundaries with her patients, and they all understand and are respectful of her time. When she says their appointment is up, it means the appointment is over, and it's time for them to go. Not once has a patient ever complained, or gone over-time, or been hostile towards Dr. Patty about this. It shows that she's earned that respect from her patients, but also that she cares for herself too! I'm still working on the self-care part. I know I tend to bend over backwards for anyone, even if I have other things to do, am stressed about other things, or it bleeds into my personal time. I need to get better at saying NO, but that's so hard for me to do because, according to Dr. Patty, I never practiced that when I was younger.

Funny story - on Wednesday I was supposed to do the entire new patient intake interview with both the patient and his mom. We didn't really know what exactly he was coming in to see us for, so Dr. Patty told me to be prepared for anything. I reviewed my DSM-5 and common diagnoses in children, but otherwise wasn't sure what to expect. I had completely forgotten that Laurie sent me a ton of "cheat sheets" on my first day, and that I could have printed them off and brought them into the interview with me. (major Aiya from me right now, haha). Anyway, I went in with no cheat sheet, but quickly picked up that the patient was there for severe ADHD. He was bouncing off the walls, couldn't follow more than 2 directions at a time, and definitely could not sit still or refrain from touching everything. However, because I didn't know every diagnostic criteria to rule in or rule out inattentive versus hyperactive types of ADHD, I didn't get to finish the interview. Dr. Patty offered to help, but I told her that I wanted to try to get through it myself (dumb move on my part). It's like I completely FORGOT OLD-CAAARTS and how to take a patient history! I didn't even get around to the PMHx, Social hx, or Family hx, which was a huge blunder on my part! I was so focused on asking questions about ADHD, I didn't even get around to collecting the rest of the history, or asking relevant questions to rule in or out other psychiatric illnesses like anxiety and depression. After the patient and his mom left, Dr. Patty told me I was the first student in all of her years practicing with Banner who didn't use a cheat sheet. *Face palm*. Honestly, I just didn't know that I could bring the cheat sheet with me! I laugh about it now, but man it was pretty embarrassing on my part. I dropped the ball hard. Never got a second chance because my rotation was short, and also because there were no new patients during the time I was there! Darn.

Anyway, a lot of self-reflection in this post... I'm sincerely going to miss this rotation, the people I've met, and Dr. Patty's patients. But hopefully, I'll see everyone again soon, and stay in touch.

On my last day I brought everyone breakfast and coffee from Panera bread. When I left, Maria gave me such a sweet thank you card, with best wishes from Laurie, Candice, and her. It's on my inspiration bulletin board at home, and is a reminder that I'm on the right path, and there are people all over who are supporting me on my journey.

I move to Sterling, CO on Sunday to begin my first internal medicine rotation at Sterling Regional Medical Center. I'm so nervous, and also sad because I have to leave my sweet cat, Millie, behind with my roommate. However, I'm excited because I know I'm going to learn a lot, and will be one step closer to my attaining my dream of becoming a doctor.

Selfie time with Dr. Patty!

1-28-2021

Last Day of Psychiatry Rotation

Left to Right: Laurie, Dr. Patty, Me, & Maria

1-28-2021

Week 21: January 17-23

two-thousand-and-twenty-one

The Highs:

Started my Psychiatry rotation with Dr. Patty!
My Autism patient
Family Liaison at NCMC
Completed my first draft of my Personal Statement
Got a haircut!

The Lows:

Stressed about preparing for residencies!

Overall rating of the week: 9/10

This week I started my 5th rotation of my 3rd year, which is Psychiatry! I was super excited to find out that my preceptor was going to be Dr. Patricia Al-Adsani, aka, "Dr. Patty", who is a child psychiatrist in the Greeley/Windsor area. I'd heard such fantastic things about her from my colleagues who already rotated with her, so I was really looking forward to learning a ton and seeing some true psychiatric pathology. Unfortunately, Dr. Patty broke her leg the Friday before I was supposed to start my rotation. I showed up on Monday morning in Windsor only to discover that my preceptor had moved all of her appointments to virtual telehealth that day. I returned home and spent the next two days studying, writing the first draft of my personal statement, and looking at potential residency programs to apply to.

Wednesday I officially started my rotation. I showed up to the Greeley clinic and finally met Dr. Patty! The "rumors" about her were no joke. She has amazing relationships with her patients, and this shows in the way they all open up to her and willingly answer any question she asks. Since my rotation was cut short by 2 weeks due to my mandatory school quarantine, she told me that I was basically going to jump right into patient interviews. From Day 1, I was helping interview the patients, asking relevant questions, and trying to figure out what everyone's diagnoses were by the end of the appointment. I found this task particularly daunting on the first day, and was really nervous because I hadn't memorized the DSM-5 yet.

However, the kids were all so welcoming and nice, and didn't mind me stumbling over my words on the first day. Dr. Patty also likes to give her patients time to play -- whether that's Uno, LEGOS, Sorry, or Checkers, the kids get to choose what activity they would like to do, and we spend a good 10-15 minutes playing and talking. I think this is a genius method to get the patients to relax and talk more. It also makes the interview less "awkward" for shier patients, and encourages social interaction.

On Wednesday, the last patient ended up being a young boy with severe anger issues, likely disruptive mood dysregulation disorder (DMDD). He seemed pretty angsty when he first came in, and was fairly abrasive on the outside. However, I noticed that he was wearing a Naruto t-shirt, and quickly knew I had found something to relate to him by, since I had watched a few episodes of the earlier seasons. We played Checkers together as he told me about him fighting with his brother, his friendships at school, and his new waterbed which helps him relax. We also talked a lot about anime, Naruto, and Seven Deadly Sins - another show that I watched on Netflix. By the end of the visit, he was smiling, so much more pleasant, and really kind. I'd like to think that having someone who understood his interests made him soften his rough exterior, and ultimately show him some compassion that he needed. He was such an awesome kid!

That first day, I also learned that appearances are not what they seem! After interviewing the first few patients, Dr. Patty and I would debrief and she would fill in pertinent information for me to better understand why her patients were there to see her. I was so surprised to hear that some of them had such tragic backstories since almost all of them seemed pleasant and kind in her office. This just goes to show how much progress each of her patients have made, and how resilient they all are.

On Thursday, we had a full day of patients in Windsor. Dr. Patty gave me some clues to improve my patient interviews - she said it was okay for me to bluntly ask why the patient was there to see Dr. Patty, and what their diagnoses were (since it was my task to find out what the diagnosis was in each patient). Prior to this one patient coming in, Dr. Patty said I was going to lead the entire interview, and I was going to have to "dig deep". Not knowing anything else about the person coming in, I just prepared myself to have a normal conversation with her.

She was the sweetest child! It took me no time to get a conversation flowing with her, and she told me all about starting school again, the friend she has, her relationship with her parents, her step-siblings, and her step-mom, and things she fears. She elected to draw/color during her activity, so we did that together while we discussed how she felt like her mom wasn't able to spend enough time with her lately, and how she felt lonely. At the end, I asked her what her diagnosis was, and she said she had Autism Spectrum Disorder. I was completely taken aback. This young girl, who appeared normal and who had a 30 minute long conversation with me, showed no signs of social inhibition. After she left, Dr. Patty said that this patient was normally so shy, she always had a hard time getting her to open up and talk. Just last week, Dr. Patty told her to ask the front desk secretary for the colored pencils, and she ended up not coloring at all because she was too shy and scared to go up to the secretary and ask. The fact that this young lady talked to me was astounding. I felt so amazing after that -- and Dr. Patty told me that she hopes I do something with the pediatric population when I specialize because I'm so great with kids! That was such an awesome compliment to receive, and really made me think about the future population of people I'd treat as an EM doctor (if I still decide to go for EM). Would I be satisfied with the number of pediatric patients I'd likely see in a full-service ED? The more I thought about it, the more I decided that yes, I'd be satisfied. Even though the peds population I'd be seeing are acutely ill patients, I think I'd still get enough exposure to fill my love for working with kids. We'll see if that changes after my Pediatrics rotation in May though, haha.

On Friday, I finally got a haircut! It was my first one since October, but I don't know if I'd even count the one I got in October because that was more of a trim. This time, I cut a decent amount of hair off my head, and added in some side-bangs! My hair is so much lighter now, and takes much less shampoo and conditioner to wash it. I love it!

Saturday, I went with Dr. Patty to the NCMC ICU to volunteer as a Family Liaison with her. Initially I didn't know what this would entail, but I quickly learned how important and impactful this job was. Essentially, we chart review all the COVID-positive patients in the ICU. Around 10:30am, we round with the ICU doctor and the ICU team on each patient, listening for updates on the plan for the patient that day. Afterwards, we sit down and compile all the information, and get to work calling each of the patients' families to give them updates on their loved ones.

COVID is such a terrible thing. After seeing the patients that day, I really understood the impact that this pandemic had on our people. Almost all of our patients were gravely ill, on a ventilator, with multi-system failure. Yes, many had underlying comorbidities that did not positively contribute to their prognosis, but it's the COVID that was taking the biggest toll. When I was speaking with each family, I would start with the worst news, getting very nitpicky about specific lab and imaging results, and doing my best to be as conservatively honest as possible. I always ended the conversation with the good news, even if that meant just telling the family that their loved one was on the lowest PEEP setting, or that their chest x-ray today did not worsen from yesterday's.

It was emotionally draining, and I can't imagine how anyone could do this job every day. I had all the more respect for Dr. Patty, who volunteered for this position, even though she's a psychiatrist. This basically meant she had to go back and relearn how to interpret labs, imaging, and understand human physiology and pathology so that she could relay correct and relevant information to the families, as well as answer any medical questions they had. For someone who's been in psychiatry practice for almost 30 years, Dr. Patty showed me that her heart was overflowing with kindness and compassion. That's the type of physician I want to become... one that is self-less, one who contributes, one who volunteers to do something that other's wouldn't do. Just constantly impressed by her, and wish my rotation was going to be longer than 2 weeks! Oh another thing... she still came in even with her broken leg, in a boot and on crutches. How badass is that.