The Running PA

Umm JUST KIDDING. I haven’t posted since ?April, my links are dying, and the tumbleweeds have moved in.

Sorry not sorry.

Life has been a struggle again these past 6 months. I needed to take some time to take care of myself (and still do!), and I was at a loss for what to write about. My blogging might continue to ebb and flow, and that’s ok for me right now, but I apologize if you send messages or questions that go unanswered.

But, I’m still here and I’m still pushing in my real PA life! After nearly 4 years at my first job I’m seriously considering moving on. I still love hospital medicine and the job itself, but our current management is not a great PA advocate and the overall tone is suffocating and disheartening. Unfortunately there are a lot of financial and logistical considerations so for right now I’m just trying hang on and not get burned out.

What have I done to take care of myself for the past year and a half?

-Took a 3 day course on addiction designed for family and friends of addicts which helped me figure out what I needed to do for myself.

-Started going to regular therapy. Individual and now couples therapy too. It’s made a huge difference in how I communicate and set boundaries.

-Regular massage therapy

-Adopted a rescue puppy, who has grown into the best cuddle muffin and is at least 75% responsible for curing my husband’s post relapse depression and saving our marriage.

-Moved to a different shift at work where I only admit patients overnight and sign them out to other providers for the day shift. No more daytime hustle and drama.

-Started a side hustle selling furniture I build through a local antique store. I help out there once in a while and it’s a great feeling to see people love my designs. It’s also great to use the other side of my brain on the weeks I’m not working.

-Most recently, I started taking care of myself physically and joined Crossfit about 5 months ago. After being ridiculously sore more often than not for the past 5 months and gaining 15 lbs in muscle I’ve actually gone down in clothing size and feel so much better.

AND coming up next in my premeditated self care journey- I’m going back to South America in less than week to visit friends in Buenos Aires! I’m hoping to blog about my daily adventures, so stay tuned for some fun and non-medical posts!

Hi! I hope that your job has some sort of mentorship period set up for you. In my case, it was a 3 month long orientation where I shadowed with each of our NP/PAs, spent some days shadowing with hospital based specialties, and gradually took on more patients. If that’s not the case for you and you’re feeling overwhelmed or unsafe, ask for something like that ASAP!

Otherwise, in terms of tips and resources… The first 6 months are hard. You feel dumb a lot, just like a new rotation. You learn who you can trust and who wants to teach you, and who to be wary of (hopefully very few people). If a little voice in your head tells you that “x” provider or nurse seems crazy or is telling you to do unsafe stuff, but you feel you should not question them because they are older, or a doctor, or have more experience than you- LISTEN TO THE VOICE! You’re probably right. If someone gets defensive despite you asking well-thought, respectful questions, it’s a red flag. Go to your SP or respected colleague and ask their advice of the situation.

Stay out of any office politics that arise as much as possible. You’re just a fly on the wall at this point.

Get some UpToDate action. Your hospital most likely has a free subscription. Get it on your computer and your phone and check it all the time. Also get Diagnosaurus, it’s like $1.99 but my most favorite thing next to UpToDate.

So I’ve been at a new job the past 6 weeks. I’m still a hospitalist, but I’ve moved to night shift. It’s a long story for another time, but basically I was getting burned out and it was either change shifts or move to a different department altogether. Because I love IM so much I am desperately clinging to it for the time being. In my current role, I only do new admissions and consults.

Since I only post now, like, once a year I figured I might as well write a nice long story for you guys! Because also, when have I kept things short, ever?

So, here you go, a narrative of my day (night?).

I leave my house, clutching my tote of Campbell’s Double Noodle soup cans, rice crackers, and Gatorade. I kiss my husband, tell him I love him, and remind him to please finish cleaning the kitchen for me. He needs a lot of reminding. I need a lot of therapy. We’ve had a lot of therapy. It’s been a year sober for him and the anniversary has been hard, bringing back the guilt big time. It’s been more down days than usual the past month and as I leave the house I can only hope I won’t get any liver patients or alcoholics tonight.

I pull in to the hospital, badge in through various doors, end up in the office. The day shift is coming to a close. “Hey!” my coworkers greet me, “Feeling better?”

“Tons! Not a hundred percent but good enough for active duty.”

My terrible med seeking external ED dump patient from earlier this week had given me her norovirus. I’d spent the previous night out sick, puking and near-syncopizing. (FYI- use the bleach wipes next time!!)

I check in with the three physicians I’m working with that night. One, a seasoned night shifter, a quiet man I dub “The Machine” because of his deftness and ease at admitting patients. One, a seasoned nocturnist, another quiet and confident man who could run a thousand codes without screaming “fuck!” not even once. The third, an exceedingly nice new residency graduate who recently started with us and is probably reconsidering the job after his first week on nights. They have a lot of patients coming from outlying facilities, but no one arrived yet.

I sit around for an hour and a half, check emails, clear my inbox of the previous day’s results and check up on a few of those patients, eat a cup of noodles, rub my belly, think about how I shouldn’t have had coffee, then, all at once, I have 3 admissions I’m called to see. Yes, it’s true, they really all do come at once.

I triage them, and go see first an unfortunate lady who is bleeding and clotting. Or rather, likely to bleed. She has a genetic disorder predisposing her to clots and bleeding, and has come in with chest pain. The chest CT showed a pulmonary embolism, one in each lung. I’d hoped they’d be subsegmental, but they weren’t. I meet with her, spend a long time talking. I tell her I’ll call the hematologist and get back to her. I put out a page.

I jump up to the orthopedics floor to see my next patient, a 73 year old lady with COPD and osteoporosis who fell down the stairs at home and probably broke her sacrum. She’s straightforward enough, other than saying she’s intolerant to everything IV opioid except fentanyl. Which she’s not going to get outside of the ED. I write for oxycodone and IV ketorolac and pray her pending labs show normal renal function.

The hematologist pages me while I’m writing patient 2′s note. He recommends a heparin drip, so it can be turned off quickly if patient 1 starts to bleed. He also says he has no idea what to do with her after that, as far as a long term plan. I text my attending and let him know the plan for tonight. While I’m finishing my note, he texts me back an SOS that patient 1 is refusing heparin because she’s afraid of bleeding.

I go back to the ED, I print out UpToDate, visit the poor lady with the PEs again. I talk about risks and benefits, types of heparin. She has some cognitive impairments from a stroke, but she gets it enough that she has capacity. She still declines the heparin, wants us to “watch her” overnight in the hospital though. I check in with bed control, ask for an IMCU bed since she’s refusing blood thinners, and am told there are no ICU beds left. She’ll have to go to the regular floor.

My third patient is a prisoner with history of peptic ulcers and GI bleed coming in with worsening anemia. Actually, he never shows up from the outside hospital because of some officer conflict. His name gets handed off to the next shift.

Fourth patient shows up in the IMCU, from an outside hospital. The notes he comes with are scanty. Acute on chronic hyponatremia, ?dementia. Hypotensive. Weak. I hope he can give me some history. When I walk in he tells me he’s in a hotel in a different state and doesn’t remember how he got here. He denies any symptoms or concerns. It’s 11 pm, but I dial his elderly wife and bless her, she’s up, and gives me the full scoop. He ends up with a slew of labs, head CT, cardiac echocardiogram.

Fifth patient was not supposed to be admitted. Just discharged 2 days ago with COPD flare, end stage COPD on home oxygen. I read the ED notes in the chart, indicating the family demanded the patient be admitted because they are unhappy and that we are being investigated for discharging her too soon, or was it the nursing home was being investigated for not taking care of her the past 2 days? Or both? The discharge summary from my PA colleague indicates the patient refused hospice the last stay. Awww nawwww. I go and see her. It’s late and at least that means the angry family has gone away. I sit with the patient, she’s very anxious, I’ve taken care of her before. I listen for a long time, answer questions, sometimes the same question over and over. She eventually admits her memory ain’t so good anymore. She then marvels “you’ve asked me more questions than anyone else has today”. I hope that’s a good thing. I go through her extensive workup and again conclude that “I am so sorry, but what you have is not fixable. I think we need to focus on trying to get your symptoms better, but we can’t cure you”. She agrees to at least have a palliative care consult. She grumbles about her bad nursing home experience and says her family called to have the bed held for the following day. I waggle my eyebrows at her “You know, if you don’t hold the bed they’ll give it up and then you’ll have to be here through the weekend and then we can see if your preferred nursing home has a spot now, But, you didn’t hear that from me!” She beams. Somewhere, a social worker has rolled over in their grave and pledges to haunt me in my dreams tonight.

I run up to my office again and eat some more noodles, drink Gatorade, rub my gastroparetic-feeling tummy, and finish up my notes just as one of the physicians strides in with a cardiology consult for a patient who just had a STEMI, now in the coronary ICU. They were found to have multivessel coronary artery disease, received a stent. “Should be easy” he says, “Cardiology has done everything!”.

Except, they haven’t. Patient is from outside our system. Needs an entire medical record update. I also notice his blood sugar is > 300 and there’s no insulin ordered. I add “Type 2 Diabetes” to his problem list. I go in and see him, expecting him to be asleep at 1:30 in the morning, but he is wide awake and surrounded by family. He’s a good soul, we have a long talk about diabetes. His wife has a lot of cardiac questions and try to answer as able. His nurse pops in. “His blood pressure is greater than 150 and they want him under that post cath. There’s no medications ordered”. I step out, sigh. Honestly, I have no idea what cardiology does or does not want for an antihypertensive in their post cath patient. I have a sneaking suspicion it also varies widely by the cardiologist. I wish they would order this shit on their people already. I’m just here for the diabeet-us. Gah! 

“What do they usually do for the post cath protocol?” I wonder out loud.

“How about some PO metropolol?” a nurse asks.

I make a face “Really? They do that?”

The nurse looks horrified “Um, yeah, all MIs should be getting that!”

I shake my head “No, I know that, that’s not what I meant, I just mean it’s not going to act rapidly and it’s not going to do much, I mean maybe IV metoprolol but-”

She looks further horrified “No, they never do IV!”

I wanted to say “but I would never give that”, finishing my thought, but instead I shrug and give up. “I’ll ask the attending.” 

I don’t work in the ICUs that often, and I especially don’t know the night crew being new at this job. It’s true what they say, sometimes you need to earn your stripes with some ICU staff, especially if you’re a PA. Also, goddammit cardiology, order your antihypertensives! And beta blockers! And statins! (Also, I love you my cardiology people out there, please don’t take my 2 AM thoughts too seriously to heart, ok?)

I trudge back to my office, finish writing notes and checking labs and imaging that have come back. The demented hyponatremic guy does not have a brain bleed. The COPD flare bounce back has a normal procalcitonin. The untreated PE has normal blood pressures. Broken sacrum indeed does have normal renal function. I order new labs for the day crew. I report out to my docs. Around 3:30 AM I hang up my coat, collect my soup and Gatorade cans to recycle, and stumble out the cold wintry parking garage. I cast a few glances, good, no creepers trolling about, get in my car, and drive home.

Everybody feels anxious about physical exams to begin with. You’re still learning basically everything about medicine, so it’s hard to tailor your exam when you’re not sure what differential diagnoses are in your head! Or what variations of normal are. You will get faster and feel more natural with time, learn to recognize abnormalities, and forget important things less often.

Depending on your job, you will tailor it to be similar for most patients so that you have a routine you fall into. For example, I always do heart, lungs, abdomen (unless the patient is eating cuz that’s mean!), extremities, mental status, skin. I add a full neuro exam for any neuro complaints. I add a check for JVD and hepatojugular reflux if I’m not sure about volume status. I do a basic orthopedic exam for joint pain complaints (but mostly I call my ortho buddies cause that is not my forte!). Etc.

A tough thing to remember is that a full physical exam rarely “catches” anything in an otherwise healthy patient, but the one time that it does it will be something serious! Oftentimes with imaging and lab work we discount the physical exam, which in my practice has led to things such as giving fluids to someone clearly in acute CHF, referring a patient for hospital admission due to “sepsis of unknown origin” who clearly has a bright red cellulitic leg, or letting someone with an acute stroke sit because the CT scan was too early to catch the spot but their exam would have revealed a coordination deficit.

I work 7 days on, 7 days off. In general 0700-1900. I can leave a little early if my work is done as long as I’m on the pager til 1900. On the weekends it’s 1700 so that the hours add up to 80 in a pay period. I also have 18 days paid vacation, which I rarely use due to my schedule, so I have a nice reserve bank. The APCs in our group split the holidays so just one of us is working on holidays, and we get to take the holiday at a different time, then. We also get up to 5 days per year additional paid time off for CME conferences.

I, like many others, am happy to see 2016 be done and over with. Mostly I hope to never repeat the absolute horror and shock of life threatening illness I went through with my husband earlier in the year. Although in reality, I know addiction is going to be a lifelong struggle in different ways for the both of us, and the anxiety of that is often active in my brain to different degrees on different days. Good days and bad days are still there, but the best thing is that the good days are more frequent as the months go by.