🌾

I still apologize profusely whenever I go anywhere to eat and have to ask a lot of questions to make sure it’s vegan.

I still hesitate saying “no” because I don’t want that feeling I get when someone continues, anyway.

I still assume the next word to come from a person’s mouth to be “cunt” or “bitch”.

I still get surprised when I’m not immediately chastised for disagreeing.

I still find it normal when a person gets defensive or angry after I try to have a conversation about the things that bother me.

I still feel guilty for having a voice.

I still find affection hard.

I still choke on “i love you”

I still have nightmares.

I still flinch at quick movements.

I still look over my shoulder.

Healing from abuse is not easy.

Healing is not linear.

You have to first focus on yourself.

Roll Down (5 min aprox)

Helps with back/neck pain

Soothes anxiety

Helps sleep

Lengthen your spine and let your body droop down slowly, only bend as far as you are comfortable with - drawing in your abdominals a bit and bending the knees. The motion should be a tad slower than the animation if possible. 

When you walk into Starbucks and you..

I. Smell the coffee aroma (olfactory)..

II. Read the order menu from about 20 feet away (optic) then you..

III.  Pupils constrict as you look at items, such as muffins, closer (oculomotor)..

IV.  You look up at salesperson then down at your money as you pay (trochlear)..

V. You clench your teeth and touch your face when they called your drink (trigeminal)..

VI. You look side-to-side to see if anyone else has ordered the same drink (abdsucens)..

VII. You smile because you realize this IS your drink (facial), then..

VIII. You hear someone say “You can sit here, we are leaving” (auditory). As you sit..

IX. You taste the sweet whipped cream on the top of your drink (glossopharyngeal)..

X. You say “Ahhhh this is good!” (vagus)..

XI. You look at the person next to you because they heard you and then you shrug your shoulders (spinal accessory)..

Tonight I had a patient come in complaint of Abd pain. No big deal really routine.

More so we thought.

Doctor comes in goes through his series of questions and starts to palpate her abdomen. She has some pain/ sensitivity in her lower left quadrant. So doc decides to do a pelvic exam.

As he is explaining to this patient what’s going to happen next. She very casually states “ okay but be careful I have leaves growing out of my cooter”.

You what?

Doc at first was skeptical has her change and we come back for the exam. And holy fuck was she right. Leaves…. growing….. that’s not the weirdest part.

Upon further inspection we realize she had stuck a potato up there. Easy to remove so as Doc is going to remove it she goes “ you have to leave it there! My insides are falling out!”

She had a prolapsed uterus and had used the potato to hold it up….

OK, this is something I feel like everyone should know…but I have seen on more than one occasion someone has NOT known, so it may do some good to make a post about it!

It’s super important to know how many mLs are held in your tubing! Like, super super important! 

The hospital I work in has tubing that hold 0.54 mLs for syringe pumps and 20 mLs for bags, but I have seen different lengths at different facilities. The volume of the tubing should be written on the packaging, so take a look at yours the next time you’re at work if you don’t know! Why it is so important?

Especially in pediatrics, we frequently give doses of medications that are smaller than the length of our tubing. In my Prostin example from the other night, the dose only runs at 0.106 ml/hr. That means it takes just over 5 hours to get from the syringe to the patient. If you primed that tubing with NS and hooked a Prostin syringe to it, your patient would be going without their medication for over 5 hours. No bueno!! You need to prime with your drip!

It’s also SO IMPORTANT TO FLUSH! I have seen this happen multiple times on the floor. Let’s say you run a 2 mL medication on your pump, but you don’t flush behind it. ¼ of their medication is left in the tubing! That can make a difference! Don’t short your patients! Even worse, say you have a dose of medication that is only 0.5 mLs. If you hook that syringe up and run it over 30 minutes……when your pump beeps, it’s only filled the tubing. Your patient has not actually received any medication at all. If you don’t run a flush, they will never get their dose! This is why if I have a medication volume that is equal to or less than my tubing volume, I will push the whole of the medication into the tubing and then run it into the patient with a flush. Obviously you wouldn’t do that if you’re running it with vasoactive drips or something….but in most situations, that is really the only way to get a patient their full dose in a timely manner.  If you do this, though, you still need to be aware of your volumes and rates. Lets say you push 0.5 mLs of medication into the tubing, then run a 1 mL flush behind it in 30 minutes….if your tubing is 0.5 mLs in length, the patient will actually be getting their medication in 15 minutes and then NS for 15 minutes. If you run a 2 mL flush in 30 minutes, the patient will get their medication in 7.5 minutes, and NS for 22.5 minutes. See where I’m going with this?

Likewise for bags, if you run a flush of only 5 mLs on a bag that was hung with 20 mL tubing…there’s still 15 mLs of medication being left in the tubing. On pediatric patients, 15 mLs is a lot!! 

OK, this is something I feel like everyone should know…but I have seen on more than one occasion someone has NOT known, so it may do some good to make a post about it!

It’s super important to know how many mLs are held in your tubing! Like, super super important! 

The hospital I work in has tubing that hold 0.54 mLs for syringe pumps and 20 mLs for bags, but I have seen different lengths at different facilities. The volume of the tubing should be written on the packaging, so take a look at yours the next time you’re at work if you don’t know! Why it is so important?

Especially in pediatrics, we frequently give doses of medications that are smaller than the length of our tubing. In my Prostin example from the other night, the dose only runs at 0.106 ml/hr. That means it takes just over 5 hours to get from the syringe to the patient. If you primed that tubing with NS and hooked a Prostin syringe to it, your patient would be going without their medication for over 5 hours. No bueno!! You need to prime with your drip!

It’s also SO IMPORTANT TO FLUSH! I have seen this happen multiple times on the floor. Let’s say you run a 2 mL medication on your pump, but you don’t flush behind it. ¼ of their medication is left in the tubing! That can make a difference! Don’t short your patients! Even worse, say you have a dose of medication that is only 0.5 mLs. If you hook that syringe up and run it over 30 minutes……when your pump beeps, it’s only filled the tubing. Your patient has not actually received any medication at all. If you don’t run a flush, they will never get their dose! This is why if I have a medication volume that is equal to or less than my tubing volume, I will push the whole of the medication into the tubing and then run it into the patient with a flush. Obviously you wouldn’t do that if you’re running it with vasoactive drips or something….but in most situations, that is really the only way to get a patient their full dose in a timely manner.  If you do this, though, you still need to be aware of your volumes and rates. Lets say you push 0.5 mLs of medication into the tubing, then run a 1 mL flush behind it in 30 minutes….if your tubing is 0.5 mLs in length, the patient will actually be getting their medication in 15 minutes and then NS for 15 minutes. If you run a 2 mL flush in 30 minutes, the patient will get their medication in 7.5 minutes, and NS for 22.5 minutes. See where I’m going with this?

Likewise for bags, if you run a flush of only 5 mLs on a bag that was hung with 20 mL tubing…there’s still 15 mLs of medication being left in the tubing. On pediatric patients, 15 mLs is a lot!! 

Pseudomembranous enterocolitis

oral vancomycin= treatment; but if ileus present = can add IV metronidazole or switch to rectal vancomycin

if the WBC > 20,000, lactate > 2.3 mg/dL, toxic megacolon (+), and severe ileus present = options include subtotal colectomy or diverting loop ileostomy with colonic lavage

*note IV vancomycin is not excreted into the colon and is therefore not effective against C.difficile colitis; however, oral vancomycin is effective

Anorectal disease

cancer should be ruled out by proper PE including proctosigmoidoscopic exam= even if benign process

Hemorrhoids

typically bleed (internal)= can be treated with rubber band ligation

painful (external)= may be surgically removed if conservative treatment fails

anoscopy should be done to rule out rectal cancer

Anal fissures

young women, exquisite pain with defecation and blood streaks covering the stools

fear of pain so intense that they avoid bowel movements and get constipated

refuse proper physical examination, and may require anesthesia

tight sphincter main problem, rectal exam may show posterior mucosal tear of anus and skin tag

in additional to stool softeners and sits baths, topical lidocaine and nifedipine areas for management

sitz baths increase blood flow to injured mucosa

initial treatment= high fiber diet and increased fluid intake

surgical intervention like lateral sphincterotomy, fissure excision indicated for fissures that are refractory to medical management

gradual dilation of sphincter can provide wider aperture for passage of stool and interrupt spasm but leads to fecal incontinence and possible recurrent fissures

Crohn disease

affects the anal area commonly

starts with fissure fistula or small ulceration but diagnosis suspected if area fails to heal and gets worse after surgical interventions

note: anal area typically heals well because has good blood supply= failure to do so means crohn’s

Surgery never the right answer for crohn

fistula= can be drained; diagnosis confirmed with endoscopic or radiographic studies

endoscopy shows focal ulcerations adjacent to normal mucosa- cobbelstoning with skip areas of disease (microscopy shows non caveating granulomas)

radiography shows strictures and towel wall thickening

tx: 5-ASA drugs, corticosteroids, antibiotics, azathioprine, anti-TNF therapies

complications: fistulas, strictures (bowel obstruction), abscesses

Ulcerative colitis

biopsy shows mucosal and submucosal inflammation and crypt abscesses

endoscopic findings include: erythema, friable mucosa with pseudo polyps,  involvementt of rectosigmoid, continuous colonic involvement

complications: toxic megacolon, primary sclerosis cholangitis, colorectal cancer, erythema nodosum, pyoderma gangrenosum, spondyloarthritis (all these can be present with Crohn’s)

increased risk of colorectal cancer and therefore colonoscopy with mucosal sampling should be offered to patients with UC beginning 8 years after initial diagnosis and repeated every 1-2 years thereafter

Ischiorectal abscess

aka perirectal abscess presents with exquisite perirectal pain enabling the patient to sit down or have bowel movements

classic findings of abscess, lateral to anus  and between rectum and ischial tuberosity

incison and drainage needed and cancer should be ruled out by proper examination during procedure

if diabetic, horrible necrotizing soft tissue infection may follow, watch closely= may require debridement

Fistula in ano

can develop in people who had ischiorectal abscess drained

epithelial migration from anal crypts (where abscess originated) and from perineal skin (where drainage was done) form a permanent tract

fecal soiling and perineal discomfort

PE shows opening lateral to anus and a cordlike tract may be felt and discharge amy be expressed

treat with fistulotomy

Squamous cell CA of anus

more common in HIV

fungating mass grows out of anus, mets to inguinal nodes often

Discipline: “discipline is doing what needs to be done, even when you don’t want to”, which means that you have to force yourself to start doing things. 

Concentration: when you make a real effort in your work (study, homeworks etc…) you will be more likely to actually focus, understand and learn. 

Organization: always set tasks and goals and organize a study-schedule. Maybe you don’t really want to plan all the week, but if you just wake up and open your agenda/bullet journal/iphone calendar and write down all the things you have to do, setting due dates and deadlines, you’ll feel more conscious and encouraged to stay on track. 

Tasks-splitting: sometimes, you write down your tasks. Some of these tasks may be very hard and complicated, and it will take a long long time to complete them. So, you can split them in smaller tasks, so you will feel satisfied after a shorter period of time, instead of studying for hours and still seeing that chapter undone on your study-schedule. 

Watch the sunrise: when I wake up late, I feel like I don’t have enought time to do my work and lose my motivation. I literally panic and then I think “whatever, I could not complete all the things anyway”. So, if you wake up earlier you will feel more positive and  controlled. 

Smart reading: try not to read your textbook just like a newspaper. For every paragraph you read, try to underline and write down key words and then your question about that subject. Literally, turn your textbook into questions. If you write down question - particularly why…? - and think about the answer, you will be more likely to remember that stuff later.