8/8 Complete!

It's been awhile.. and a lot has happened.

Today officially marks the LAST day of my clinical year rotations. The next time I will be a PA student on rotation I will have graduated college and obtained a bachelors degree, spent an entire week celebrating my final days of college, and enjoyed a month off of rotation. It seems like just the other day I was stressing, staying up all night long and so incredibly nervous for my first day at the JCC. Fast forward 1 month, putting back on my white coat and entering Richmond University Medical Center for my psych rotation, the butterflies kept coming. Today I walked out of my last shift at Forest Hills Hospital in Queens, NY after working 7PM-7AM with 1 C-setion, 1 vaginal delivery, 2 ER consults, and countless triages so proud of how far I have come.

Now let me recap on these past 2 months of my life. After pediatrics I spent 4... very long... very painful weeks on Internal Medicine. I have a great deal of respect for hospitalists. They are responsible for overseeing the entire medical production of a hospital patient's care. They manage patient's everyday care, following up on all their necessary consults, and creating a disposition for appropriate care after discharge. But that is all they do; they sit behind a computer ordering medications and consults and waiting for the consults to be fulfilled. There is hardly any time taking or caring for the patient directly. I missed the lack of connection between myself and the patient. I missed doing procedures, no matter how simple they may have been (like a blood draw). I was more than excited to end that rotation and start OBGYN.

Of the 8 rotations I have completed this year, OBGYN has been the BEST rotation I have been on. I loved going to work everyday and seeing the wide variety of different patients and clinical scenarios. Additionally, the hospital I was at utilized PA's in the most effective way. The PA's managed the entire floor, were the ones treating and managing triage patients, performed all the ED consults, and were first assist in all the GYN surgeries taking place during that day. So essentially, the PA did everything (unless they let a student perform a procedure). None of my other rotations allowed PAs to have that type of responsibility and autonomy and it made me realize the full potential I could have when I start working.

Not only did I get to do so much clinically, I also fell in love with the OB population. I loved helping women through the birth of their child. From the moment they walked into the triage room excited because their water broke, through the painful and long hours of contractions, to pushing and pushing and finally until that moment when baby pops out and they are holding their child in their arms. The level of trust the mother and family has in you and their staff during those moments and close connections you make in just a few hours is incredibly rewarding. Of course there are moments when things do not go as planned and there are medical emergencies, but the majority of the patients and encounters are positive and self-rewarding. I love that you get to follow through with patients from the moment they walk into the door, through their delivery, and in the 2-3 days after delivery with their postpartum care.

And I did more than just OB, I got to do so many surgeries. The PA was first assist for all C-sections and all GYN surgeries (hysterectomies, D&C's, ovarian cyst resections, etc). There was even a few times when the PA was not able to make it to the surgery because the L&D floor was so busy and I was the one first assisting on the surgeries! I knew that I did not know much going on during the surgery and had to be walked through the steps, but the surgeon (who was also the department director of OBGYN) recognized I was a fast learner and said I picked up the surgery skills quickly.

The most exciting part of this rotation is that I may have been offered a job. The senior PA I have been working closely with said that when I graduate, apply for this position and she will get me a job. She recognized how hard I have been working these past 4 weeks and how much I enjoyed my time at rotation. I was surprised how much she wanted me to apply for a job (even if it is a year in the future) and how much she thought I'd be a great asset to the team. Of course now I have to think about if this is what I want to do post-grad, if I want to work in Queens, where I'll live, and trying to work out with the faculty directors at my College the opportunity to go back to Forest Hills for a second rotation with the department.

For now, I am so proud of myself for all I have accomplished during this year. I am so much more confident in my skills as a PA. I know the type of clinician I am with patients and the approach I like to take. I know how to make a patient feel comfortable with me before I start asking the invasive questions or before I stick them with needles for blood and IV access. I feel more conformable taking on complex patients and learning about their illnesses.

Heres to finishing this semester strong and enjoying my time off during the next month.

The Light is Coming

People tell you, "enjoy every moment it goes by so fast." I really hate that phrase because sometimes you just want things to be over, but I truly never imagined that my time in PA school would go by so quickly. The other week we picked our rotation tracks for graduate year, WOW! I remember being a freshman walking to my Anatomy I class staring in aw at the PA students with their white coats on. It looked like they had every aspect of their life together. Little did I know that dressing professionally and throwing a white coat over you shoulders can make the most sleep deprived, over-worked, stressed person look put together from an outsiders point of view. It is finally hitting me that my first year of clinical rotations is almost complete; there is only 2 more to go before graduation.

Even more shocking is that I am going to be graduating college in a few weeks. While it doesn't really feel like graduation because I'm walking on May 20th and will be back on rotation June 6th, I still get to walk across that stage with a gown and cap and I will be handed a diploma. I have to say goodbye to some of the greatest friends and memories I have, and that is what makes me the most sad. I have said so many times that I never loved my college, but I definitely made the most out of it and have had so many wonderful moments with amazing people.

I have been waiting to write this post until I had a final schedule for my graduate year, but I feel like that moment will never happen so I'll write what I have so far. Graduate year, in general, is chaos. All of the rotations seem to be off Staten Island and are located in Manhattan or New Jersey. I am nervous for the commuting and the level of knowledge expected from me as a student. Regardless, the rotations I have selected are going to be incredibly exciting and challenging, and I'm ready.

My first rotation is Urgent Care at Brookdale Community Hospital in Brooklyn. One of my goals when picking tracks was to get a rotation at this location. It is located in a somewhat sketchy part of Brooklyn and people are brought into the emergency room after sustaining stab wounds and gunshots. I figured, if I am going to do emergency medicine and urgent care, I want it all. Also, this location is a Level I trauma center, which I am incredibly excited about. I loved trauma while on my surgery rotation and I wanted to have an entire trauma clerkship, but it didn't work out (as I'll explain later). What is also different about this rotation is that during the 4-weeks I only have to work 12, 12-hour shifts; that's 3 shifts a week. I have a lot of flexibility in my schedule and I just have to make sure I get to each department at some point during those 12 shifts. While this will be a culture shock as my first rotation, I think I am ready for the challenge.

My next rotation is a clerkship. Clerkship are a 4-week rotation where we get to choose any specially that we are interested in. Originally I was going to be do transplant surgery at Mt. Siani Hospital. This was the ONLY rotation I wanted and something I was so excited for. Unfortunately, I was not able to get this clerkship after originally being told I was accepted. I was supper bummer because 1) I know they are hiring and I would potentially stay in NY if a job presented itself, and 2) when else would I get to try out transplant surgery and fly on a plane to harvest organs, that is SO cool! Everything happens for a reason and I am just going to have to trust that I will get a great clerkship to fill that space.

I start my fall semester with neurosurgery at Weill Cornell Hospital. I was pleasantly surprised to find this rotation offered since before we only had 1 location for neurosurgery and spots were limited.  I was able to observe a craniotomy while on a 24-hour shift during surgery and it was amazing. I don't care if I only get to observe the surgeries, I just want to see that again. I am quite excited for this month.

I then get to stay on the Island of Staten for my NICU rotation at Richmond University Medical Center. I am so nervous for this rotation. When we had newborns brought into the pediatricians office for their first wellness check, I had no idea what to do and I had no desire to touch the babies. The last thing I wanted was to touch them and do something wrong, and these babies were healthy. In the NICU these babies are sick with tubes and lines all over their small 2 or 3 pound bodies. It will be an interesting month, most likely filled with fear and nerves.

After the NICU I head back to Brookdale for my emergency medicine rotation. While EM and urgent care are technically supposed to be different, at Brookdale you do the same thing regardless of the rotation you are on. I hope I like it the first time because I have to go back there.

I finish the fall semester with my second clerkship. Again, I currently have no rotation set up. I originally was going to be placed at Jersey Short Trauma, but the rotation can not accept any students at that time. I asked to be placed at a rotation at Mass General Hospital in Boston in the Orthopedics department. I'll be honest, I HATE orthopedics and I am so nervous I will pass out in the OR hearing bones broken and set. I also have no place to stay if I were in Boston, so I'm hoping something else presents itself and I don't have to go there.

The spring semester is short, with only 2 rotations. The first is my advanced medicine rotation at Jersey Shore Critical Care department. I didn't think I would be excited for a critical care/ICU rotation because it is filled with really sick patients who are always dying, but I think I can use this rotation to learn a lot about general medicine and how to manage critical patients. The commute will be interesting (an hour each way), but I'm thinking the drive will be worth it.

My final rotation until I become a PA-C is long term care. Typically, students spend a month working 10AM-12PM (only 2 hrs) at a nursing home. There is nothing to do except look at pressure ulcers; I am not too excited about it. Instead, I'm trying to coordinate a month rotation in Guatemala. The people and culture of Guatemala were life-changing and I am trying to find a way to go back. This rotation would be much different from Belize and a lot more rural/off the map but I am so excited by the possibility. If this ends up being a reality, I better start practicing my Spanish medical phrases; I won't have translators this time!

There are so many exciting events happening in the next year: finishing senior year, graduation, amazing rotations, becoming a real PA. I can finally start to see the light at the end of this incredibly long tunnel. I want it to hurry-up and happen so I can experience everything, but I also want to live in each moment and enjoy every second. Nonetheless, it is going to be an incredible year.

Little Humans

After having been on my pediatrics rotation for the past two weeks, I think I can firmly say this is not a specialty I will find myself going into in the future. The more primary care rotations I completed (this will be my third) the more I know I cannot be in the field of primary care. I find myself so bored 85% of the day. I take histories the exact way they have to be logged into the computers and do physicals on healthy children. The majority of these children have nothing wrong with them, which is good and exactly what I would want, but as a student I miss the challenge of seeing complex patients and creating a list of differentials and possible plans.

What I do love about primary care, and what I have benefited a lot from on these rotations is learning how to talk to patients and form bonds with them in a short amount of time. One of the first patients I had when I began working with a new doctor at the peds office was a 6 year old male who came in for an asthma followup. 1-month previously, the boy was having symptoms weekly and woke up multiple times a month with asthma attacks. The doctor placed him on a new inhaler to help stop his attacks. On his follow-up visit he was no longer having asthma symptoms and has only had to use his rescue inhaler one time in the past month. Since I'm in peds I try to be really up-beat and happy when I see everyone so that they don't get scared of the doctor and fear coming back. I gave this kid a high-five and told him how proud I was that he was taking his medication everyday and no longer having symptoms. I finished up and did a quick physical before going back to present the patient to the doctor. We both went back in and the doctor asked a few questions over and did her own physical. We told the patient to keep it up and that we will see him in 3-months for another follow-up, but before he left he whispers in his mom's ear "can I give her a hug". The mom and son both look at me and I look at the doctor who shrugs her shoulders to say it's fine, so I tell the kid "sure." He goes in for a quick hug and says "thank you."

Never before have I had a patient ask to hug me because I did a check-up on them. In the moment I didn't know if it was inappropriate to be hugging the patient or if I should be proud because he really appreciated my ability to relate to him and make him feel better. Pediatrics has brought a new level of emotion into my life. These children are either really scared and you have to spend a lot of energy trying to convince them that you won't hurt them and that you just want to make sure they are okay. The other half of the children look up to you as an authoritative figure and you have to make sure you are happy, upbeat, and promoting good lifestyles and healthy choices in a motivating (not accusatory) way. It's nice to feel that the children really appreciate you being there (even if you're a student).

Another touching moment I had occurred on Valentine's Day. An 8 year old autistic boy was brought in by his mother because he had been complaining of a sore throat and chest pain for two days. Even though he was autistic, he was verbal and able to tell you a little bit about how he felt. I asked him about his "chest pain" and he said his heart is beating really really fast. I asked if he was nervous being in the room and he said no, he was heartbroken. His mother and I looked at each other and we both let out a laugh. I asked why he was heartbroken and his mom asked if he had a girlfriend. He kept saying "Gianna broke my heart" over and over while pointing to his chest. It was the most adorable and heart breaking moment. This little boy was so vulnerable and laid his heart out for everyone to see and he didn't even know it. I loved witnessing this tender little moment.

These little humans I spend my whole day with are so different, yet so similar, to adults. They have no filter and say/do the funnies things that adults would never do. These little moments are definitely necessary for making it through an otherwise boring day.

The Sweet Sound of Screaming, Crying Children

This week I started my next rotation: Pediatrics! 

I am doing my pediatric rotation at Beacon Christian Community Health Center. This office is a New York state funded clinic serving all types of people with all insurances and even without insurance. The clinic's mission statement is to "Honor God by caring for the physical, mental, and spiritual health of the community." I did not really know what to expect from this type of clinic. It is very different from every other place I have been at. Obviously my experience here would not be as drastic as Guatemala, but I knew I would still see a lot of economically challenged patients. 

On my first day I talked to my medical preceptor and she summed up very nicely what the clinic is all about. She explained that since the clinic is federally funded, the emphasis for each patient is more than just addressing their medical problems. Each patient needs to have equal parts education on diet, exercise, education, driving safety, etc as education on their medical problems. The doctors at the clinic get paid much less than a private office because they each have a desire to serve and help the people of this community and give them an equal chance to receive quality healthcare. After spending the beginning of this year in two countries surrounded by people with minimal access to healthcare, I have a new level of respect for this type of clinic. It is refreshing to see that there are places and people no matter where you go focusing their effort and energy into people that have less than you do. I feel honored to have the ability to rotate at this office. 

Everything the clinic does really focuses on bettering the health and home life for children. Every child under the age of 6/7 receives a book as part of the Reach Out and Read program. This program was started in Boston and has spread to all 50 states. It provides a book to every child in impoverished ares to stimulate reading, growth, and development of the brain. This is something I never would have though of, had I not seen it. If a doctor is handing a child a book, either a picture book or even one with words, they are more likely to read it, enjoy it, and ask for more. Additionally, the parent is educated on the importance of reading to their children at a young age and eventually having their children read on their own when they become older. The level of reinforcement of important social skills is remarkable in this office. 

I am also already learning so much. One of the families I saw on my second day was quite challenging. A father brought in his two children for physical exams and shots. Recently the children's mother had passed away and the kids were left without health insurance. The father is wheelchair bound after loosing a leg and does not have his own health insurance so him and the kids are left uncovered, hence their reason for becoming new patients at this clinic. The first child was an 8 year old boy with Autism. He was a very obese boy and a little aggressive, but able to communicate. I have never been more thankful for my rotation at the Eden II school (a special school for children with severe Autism) than during this encounter. Between the knowledge I had learned at the Eden II School about effectively talking to children with Autism and some additional health history from dad, I successfully obtained a complete history. What an accomplishment! 

The other patient was a 12 year old female who had an extensive history of asthma attacks that had caused her to be in the ICU 17 times. There was this and many other medical issues in this child, which became quite confusing at times. Throughout the entire interview the father didn't really seem to know what was going on and was a questionable historian. He didn't know the name of medications the children were on, he kept telling bizarre stories about certain health concerns for each of his children and overall seemed confused. The doctor told me to take my time obtaining their history since they were new patients, and once I left I realized I had spent 40 minutes getting their complete histories and establishing the patient's goal for this appointment. I told the doctor everything I found, and his first response was "wow, this is complicated;" however, he also complemented me and told me I did a great job finding out everything we needed before going in for the physical examination. 

I was very proud of myself for tackling this complicated case and being successful. It made me realize how far I have come in the past few months and how important it is to learn from previous rotations and previous mistakes. Very few patients are "easy" and no clinician is perfect, but practice makes perfect. I am very excited to continue learning more from this rotation, both medically and socially. 

Back to Reality

The moment I landed back in the United States I almost shed a tear. You don't realize how much you miss being away from home until you finally return.

I loved being back in my own home with the familiarity of our living room and kitchen. I missed sleeping in my own bed and being able to put away my clothes and not live out of a suitcase. I missed my other roommates and being able to share stupid stories with them. I even missed our downstairs neighbor and her addictive cigarette smoking (she's good for a lot of jokes).

What I missed most was going grocery shopping and being able to cook all of my meals. I had the opportunity to try so many different foods and cuisines while in Belize and Guatemala, but there is nothing like being able to grill your own chicken to enjoy it over a salad. The grocery stores were a bit of a culture shock and I forgot how many different American brand foods there were. Even though there were so many good items to choose from, I do miss all of the fresh seasonal fruits available in the grocery store back in Central America. The pineapple here is way too expensive and definitely not as sweet as the ones in Belize.

I am so thankful to have had all of the opportunities that have presented themselves in the past 5-weeks. From working in a clinic in Belize, to snorkeling, feeding a monkey, going to 6 different village in Guatemala, and zip lining (twice!) there has been an endless amount of memories. I had originally planed to keep this blog as a way to remember my trip, but have decided to keep it going through rotations. It's a great way for me to remember all I have seen and learned during the busy weeks at work and for me to see who far I have come.

Feel free to keep following my way through PA school (and life in general)!

Nothing I love more than my own bed and writing about Guatemala 

Sometimes You Wish You Could Do More

While the majority of the class decided to hike a volcano for the day, I hung back and had plans of resting and lounging by the pool for our final day in Guatemala. While I had planned to just relax for the day, I found myself reflecting on this past week and weighing the pros and cons of our trip.

With each village that you enter you find yourself being able to help patients really well in some areas and not being able to do anything for them in other aspects. The number of children we saw who had scabies was initially surprising, but towards the end of the week something normal. The pharmacy had enough cream for each family to put on the children to control the itching, but that is not enough. The patients need education on washing their clothing and bedding and giving it enough time to kill the bugs. Some of the patients didn't even understand that the rash on their body was from a bug and they thought it just occurred from some type of internal infection. We tried our best to explain how to fix the situation, but between the language barrier, lack of available time to thoroughly explain, and inability for the families to have the necessary resources, we often found ourselves at a standstill. It is frustrating to know that you can treat the problem for a few days, but it is going to keep happening and there is nothing you can do about it.

Another similar situation we found almost everyone to have is a chronic cough and sore throat. Through observation and talking with my professors and locals I learned that all of the homes in the outer villages in Guatemala use wood burning stoves to cook without proper ventilation to rid the house of the excess smoke. Additionally, to get rid of all trash, families create a pile in their yard and set the trash on fire to get rid of it. People are being exposed to thick smoke all day long, some of which may contain harmful chemicals from the trash, so it is no wonder they all have sore throats and coughs. When you look at the problem, yes, we can help with the symptoms and give some cough drops, but we cannot fix the root of the underlying cause. There is no way we can go to everyones home and install a gas stove or go to the government officials to enforce trash pickup and ban burning of trash. These matters are completely out of our hands and level of practice.

The majority of the problems we saw stemmed from lack of financial wealth. To put it simply, we served the poorest of the poor and people who had very little. Children presented with loss of appetite and distended bellies because they have a parasite, which come from unclean drinking water and contaminated food. This is the food they have access to and there is nothing else. Other patients presented with a laundry list of complaints and it is not because they had all of them at that time. It is because they have experienced each of these symptoms at some other time and want to know if there is something available to help should they ever experience that type of pain again. They cannot afford to go to the doctor for a checkup, let alone go to the pharmacy to pickup some ibuprofen for their headache.

Some of the most difficult moments I had during this trip, in regards to lack of access, were moments focused on female and maternal health. In the United States most women (definitely not all) get a PAP smear at some point in their lives to screen for cervical cancer and have access to services specific for women should they have a GYN or breast complaint. In the US, women who are pregnant go to see an Obstetrician and take prenatal vitamins enriched with folic acid and iron. If a woman does not wish to become pregnant, there are a variety of different birth control options available to choose from. In Guatemala, women do not have access to any of these options.

If a woman came in with vaginal discharge she often has had it for a very long time and no one has ever examined the issue. We tried our best to figure out the problem, but we as well did not have the appropriate space to privately examine the patient or equipment to do make a proper diagnosis and treatment plan. Moms we saw who were pregnant were not taking prenatal vitamins or any type of multivitamin; vitamins are too expensive. Additionally, we saw so many children because there are no family planning options or education available to teach women about pregnancy and spacing pregnancies. We saw women at the age of 18 with already 3 children. It was heartbreaking to find out how women's health is treated in Guatemala. The women in the village are responsible for maintaining the household while the men go out to work. They have to care for their children, cook the food over wood stoves, find clean water, and walk miles with their children strapped onto their back to surrounding villages to sell goods or food, which they carry on their head. These women are so brave, bold, and hardworking yet they have no access to medical care. It is devastating to see the women who care for everyone else not have access to the care they needed most.

I can think about all the things I wish we could do more of: more vitamins, more medications, longer hours to see more people, more time to sit and educate patients, etc, etc, etc. I keep reminding myself that we DID make an impact on these villages. We went to 6 different towns serving over 800 people in only 4 days. We gave out every last item we had to everyone we saw. We provided medications to people, told people they would be okay, and even told people they were going to be a new mother. There was so much joy and reward during the four days of being in the village that I have to tell myself that we did make a difference and our weaknesses should only be a driving point to make the next visit even better.

I hope to be a graduate leader for the group next year who goes to Guatemala. I have a lot of small ideas and suggestions to make the trip an even better success. Things like an education stop before the patient receives their goody bag, bringing a large set of teeth and giant toothbrush to teach kids how to brush their teeth, bringing a privacy screen with a table and equipment to do a vaginal exam or have a patient lie down to check a fetal heart rate would be a few small improvements to an already extremely successful operation.

I thank everyone I had the opportunity to work with and the Wagner PA program for this unforgettable experience. I am so thankful for all of the people I have met and will never forget. I cannot wait until the next time I am back in Guatemala.

Feeling more blessed than ever for experiences such as this one

Zip Lines (Take 2)

I had been saying since the day I arrived in Guatemala that during the two days we had off for ourselves, I was planning on relaxing and laying by the pool before heading back to reality. The first day for excursions finally arrived and what did I decide to do, go zip lining.

Getting ready! 

I am very thankful I made this last minute decision. The lines of this course were 10X more amazing than the ones in Belize. To reach the lines, we first had to hike up the mountainside to the higher altitudes in order to reach the lines. We had to cross swinging bridges to get from one platform to the other, all while looking down at the trees and greenery below.

We even went over one swinging bridge where we had a full view of a waterfall. It was beautiful and such a peaceful moment to enjoy between sweating and puffing up the hills.

Finally we reached the first of 10 different zip lines. The thrill of speeding down on a rope and being help up only by a cable and clip is indescribable. The combination of an adrenaline rush from the line and the beautiful views of the forrest, lake, and mountains and the entire experience is indescribable. Check out the photos from the lines:

At the first of 10 lines 

View from the middle of the line

Coming in for landing 

Arrived

Having some fun in while landing

One of the lines required taking an extra hike up the side of a rock and onto a platform before taking the 20 second line across the forrest from one mountain to the next. This was the highest point of the hike and of course I had to take a picture of everything we saw.

Hiking up the rock to the platform

All the way on top!!

Once we finished all of the lines, we reached the final part of the day: the ropes course. The first part was quite simple and no one fell. The second part... was a disaster. The course consisted of swings and you had to walk from one swing to another all while suspended in your harness. I definitely thought it would be easy but the moment I stepped onto the first swing I realized otherwise. On the second swing I took a huge fall and was left hanging in the middle of the line. Thank goodness for all of the people I went went for cheering me on and helping me figure out how to stand back up and make it across the ropes.

At first I was doing okay...

And then it all went downhill 

It was a fun morning and great way to spend time with my class outside of the clinic. I loved seeing more of the nature in Guatemala, including some of the monkeys in the trees. I fished off the day lounging by the pool and reflecting on the days in the clinic.

During the day at the pool we even saw a couple come in on a helicopter for a drink and lunch, wow!