I must have done something right...

Today was a good day...

"Do you want to do your evaluation now?"

"Sure." I say kind of excitedly.

I'm sort of like Angela from 'The Office' in that I think I thrive on being judged. It's not something I'm proud of, but it's sort of true. I think it stems from the fact that I feel it necessary to continually prove my worthiness as a PA student because of my less than stellar Undergrad grades.

Let's just say I pulled down my class average.

So, from that point on, I worked hard to make sure that any judgement passed upon me, as a PA student, would be positive. And if it's not, then I deserve that too... and I can take it and make the necessary changes to become the best PA I can be.

So, Bring it on Kalauawa... bring it.

I guess it's unfair for me to say that I had worry running through my mind, he had already said that he'd given me a good review, and I was one of the best students to come through the joint. (wow... I've got him fooled!) And I must say, that made my day.... REALLY made my day.

don't let it go to your head, dummy. you still have it in your amazing screw-up power to SCREW IT UP.

So I followed him down the hall to his office. I have a seat in an old wooden chair. It matches the rest of the clinic perfectly, in that it appears old, worn and unimpressive. But once I get into it, once I give it the smallest chance, I love it. It's as comfortable as any office chair I've ever sat in. It exceeds expectations.

Before I can even get a word out....

"Off the record, I think all this stuff going on between the Vikings, the Packers and Favre is crazy. They're all talking to eachother... I think Favre will end up with the Vikings."

(He is a huge Vikings fan.)

This is NOT the first time we've talked football, and this conversation lasts a few minutes. When it's over, both agree that if Favre can't play in Green Bay (which we both think is the right thing to do) that we want him to play for Minnesota.

He then, sans segway... save maybe a little sigh fading from the tail end of a laugh, shows me my ratings.... all above average, except for one, which is average. He tells me this is the best rating he thinks he's ever given. He gives an 'average' rating if you are where he expects for you to be, as a competent student.

Now, at my last rotation, I received all 'Superior' ratings... but that was kind of meaningless. They didn't put the time and effort into it that Dr. K did. I think they just liked me. Not that I did poorly, they told me that I did well, but I doubt that I was 'Superior' in all aspects of the rotation.

Whatever the case may have been then, after hearing Dr. Kalauawa's review of my performance, I'm flattered, happy, proud... and feel like a fraud - all at the same time. I think they're all valid things to be feeling at the time. This, I've decided after more than a few minutes to think on it.

But then came the whammy...

"So what I'm saying is that when you're looking for a job, if you want, you've got one here."

I'm speechless, really. They told us at school,before the shoved us outta the nest, that this might happen, and yet, I was not expecting it.... not at all.

"Wow, thank you! That REALLY means a lot to me."

As one of my old stand-by bands, Relient K, once said, "I must have done something right..."

Shoot....

it did occur to me that maybe he says the same dang thing to everyone who rolls through threre, but hey... it made my day none the less.

Now I just have to finish my flippin' geriatric mental health case study thing..........ughh. did the day just get worse?

a serious case of the spins...

Just a few things I'd like to mention to whoever might be reading this....

1. I made pasta tonight for dinner, and made a nice little white sauce to go with it. It ended up tasting pretty good, but my foot paid the price.

I feel like Michael Scott; I burned my foot in a cooking accident. Really.

I can't say I did it by stepping on a George Foreman grill, or that I'm wearing bubble wrap on it.... or best yet, that I tried to stick it in a CT scanner while a friend of mine was having his head checked out, but it happened. I was busy chopping garlic with that crazy Emeril chef guy... and before I knew it, my pan was HOT, and the olive oil was smoking... so I turned it down a bit, and realized I might need a BIT more olive oil. So I went to pour a bit more on there....

Well, I must have been going for a long distance pouring record, subconsciously... because the force that the oil built up on its seemingly endless fall to the screamingly hot pain was enough to send smoking hot oil flying from the pan, to the top of my unsuspecting left foot.

Poor left foot, he was just down there, minding his foot business... keeping me properly balanced on the floor... maybe he was even enjoying being naked... who knows! (I bet he was) Well, if he WAS, he must have quickly wished that he had been wearing his ol' buddy socks and shoes as soon as that soaring glob of pain found its way to the top of his bare skin.

I think I heard him call out in pain....

He's been bathing in ice for a while now.... and feeling better.

2. I watched a homeless guy spin circles in the park yesterday.

He would spin counter-clockwise for about 3 or 4 minutes, occasionally slowing down just a bit so he could take a drag off his cigarette, then he would start spinning clockwise for another 3 or 4 minutes.

His footwork was amazing.... and so was his whole ensemble.

He was wearing some fire engine red shorts, they looked like swim trunks, and were a little too short. He accompanied these with white socks up to mid calf and then some classic tennis shoes. He, of course, was shirtless. and this 60-something must have been in the midst of some massive beard-off with a friend or two of his... because this thing was amazing... almost as amazing as his equally long hair, which only paled in comparison to his spin moves.

Tony Hawk, watch out! A 1080 is child's play.

Once he was done spinning, he quickly started talking, to, well... nobody. but his hand gestures were grand, as if he were in some sort of terribly heated debate. They were swaying this way, and that. Up in the air, over his head as if appalled. Then he'd point with his right hand, still clasping cigarette, as if to accuse his adversary of some terrible deed.

I'd look to where his gaze and hand gestures were landing. I only saw birds.

Those birds must have really done something to deserve the tongue lashing that they were getting from this guy.

They didn't seem too scared.

3. DVT guy still has not gotten all his results back yet. We still don't know why he made a massive clot. Which brings me to my next point; I made my first house call the other day. I went to DVT guy's house and checked up on him, his leg, his heart and lungs. The clot did move up a bit, according to the second ultrasound, but it sure isn't in his lung. But his leg is awfully swollen (for you nerds, it's about 2+ pitting edema) and it's still hurting him. poor fella.

Hope that all gets resolved soon.

4. Anyway friends, I don't like any of you, not even a little bit, and I'm certainly not excited to see you all very soon. Nope, not excited at all.

P.S. Figure out which one is the lie.

thumbs down...

The thing that I do like about Internal Medicine, or Family Practice, is that I get to see the end of the story, instead of being left with endless cliffhangers like in the ER.

It was always like I got to watch half of a movie, and just when it was getting good, just when I was hooked, some jerk turned off the TV... or the sattelite cut out, or the DVD was scratched beyond repair. I once actually had lightning strike right outside the door of my place where I was watching a movie, not 20 feet away. It fried the VHS right in the VCR. (yea, it was in the VHS days.) That was a serious let down... what happened to the protagonist? did he get the girl? did he achieve his seemingly impossible dream? did he survive the barrage at Bastogne? who knows..... and now that the tape's fried, you're not gunna.

well, that's how it often was in the ER. we could often figure things out, stabilize and such. but even with a diagnosis, there was often further workup and treatment. I never knew what happened to these folks. Did the guy with the AAA we found make it through surgery? Did the lady in DKA ever get out of the ICU? well, who knows... so pop in another movie... 37 yowm, overdose, just barely breathing...... wonder how this one will end. however it ends, i'll never know.

But in the clinic, I get to see page one to page done. well, at least for certain things. Diabetes isn't ever going to just end... COPD... these things go on, but there are tenable endpoints and concrete answers to certain questions here.

Take for example my 31 year old male who came in a few days ago for leg pain. He had run home from work a few days ago, and woke up the next morning with what he said felt like a pulled groin. So he'd been trying to take it easy, but still had been going to work where he's on his feet all day. So now his calf and part of his hamstring were bothering him. He figured he'd been sort of compensating for his hurt groin... walking differently, using different muscle groups.

Well, this sounded about right to me. His history sure made sense for this, and his physical was pretty normal, his calf was awfully tender to palpation though... awfully tender. and is that R calf looking a bit larger than the L? hmmm.

I go back and talk to my preceptor, who's an awfully good PA, and told her what I found on HX and PE. I told her what I thought it was, most likely, and what I wanted to do. (On a sort of side note, she asked me what I thought about Homan's sign, and I said it was bogus... that it had a low specificity and sensitivity, so I didn't do it. Thank you Prof. Randolph.)

So we go back in there and tell him that we are going to give him something for the pain, that it's most likely a musculoskeletal injury like he thought. We went on to tell him that to be on the safe side, we wanted to send him for a right leg ultrosound to rule out a DVT.

Tick, tock.... tick, tock.

A few more minutes pass in the movie.... our protagonist is off to battle.

A few more minutes elapse on the DVD.... (2 days pass) and our hero returns.... I see him limping through the waiting area. It seems his wounds aren't yet healed.

He arrives to the nurses station, looks over at me, and after a smile and "Hey!" from me, he smiles back, but gives me a double thumbs down as he shakes his head.

I already know what has happened.

"Not good news, huh..." I sigh.

"Nope." he replies, with a sort of sad smile.

"I'll be in to talk to you in a minute."

It turns out that our friend did actually have a popliteal DVT. Which explains the extreme tenderness to palpation of his calf, worse as you neared the popliteal fossa. It also explains why his right calf appeared a bit more swollen than his left.

He had already been started on Lovenox the day prior, right when he got the diagnosis (an anti-coagulant for you non-geeks.) and he was here for another round of shots, 80 mg subQ of Lovenox. We also started him on Coumadin (another anti-coagulant, but one you can take in pill form.) so we could get him off the heparin in a week or so, once the Coumadin was in its therapeudic range.

He's only 31 years old, a 5 pack year smoking history, (a kind of wimpy smoking history). NO other risk factors for DVT. This meant that our movie is not quite near the end.

We needed to do some more looking.... this meant bloodwork for things that could cause a hypercoagulable state, one of the most likely being a coagulation cascade factor mutation called Factor V Leiden. So we got more blood from him, sent it off to lab, and sent him home.

The story will continue tomorrow.

Lets pray this isn't a 'Lord of the Rings' trilogy... Let's pray it's a shorter movie... shorter is better for this hero. Lets pray that this movie ends with a Factor V problem, he can live with this. If everything comes back clean, and the movie gets longer, it's because we need to go cancer hunting... I don't want to go cancer hunting.

I'm in the mood for a good thriller of a movie, some mystery, some suspense... but I'm a sucker for a happy ending. I live for the happy ending.

I'll let you know if this has a happy ending. But at least I get to see the rest of this movie, because I'm hooked.

*the previous story is HIPAA compliant. names have been excluded, dates, sexes, ages and such have been changed to protect the innocent. (and they always will be on this blog.)*

what's in a number?

I've spent a good part of my day today crunching numbers. So now, my head hurts... oh, not because of the numbers, or the math.
I'm a math-a-magician. echem... right. My head hurts because I smacked it on a cupboard as I was standing up to put a pan on the stove.

BAM!

"Not now, Emeril! I just hit my head you JERK! and always with the 'bamming' and all the food.... ugh!"

that's beside the point, I'll survive, and I won't even have a mark to show for it.... but the point is this.

I don't have one.

At least I don't have one anymore, maybe I did when I started... but I've forgotten now. Maybe I'm tired, it's tough to sleep when a jerk Chef is always yelling and cooking and going on and on about garlic into the wee hours of the night. Or maybe my head is hurt worse than I thought.

In any case, I'm out of words for the night. More to come later...

love.

it's hammer time...

today, while at my favorite subject (unmolested the entire time) I was quite entertained for precisely 60 seconds.

I was sitting at a small table, in the shade, between the beach and the utlra-wide sidewalk to accomodate all the tourists. It seems to me that this sidewalk is, at least at high tide, wider than the actual beach at Waikiki. It's not that the sidewalk is that incredibly wide, but it's that the beach is excessively narrow. (Waikiki Beach is actually not all that impressive in 'Beach Quality.' It IS however, quite high in 'People Quality.') There are MANY people, too many people in my opinion. To lay on Waikiki Beach and try to get some sun seems to remind me of the national geographic channel. I mean that these people remind me of Elephant Seals, splayed out in, often times, disgusting positions, sweating on and snarling at those who come too close to their space; which is everyone. There isn't a grain of sand that goes untouched in any given day. This is good for people watching from the sidelines, but this is not a Hawaiian beach, at least as I imagine it. It's a meat market.

So it was at this meat market that I was eating today, as I do everyday, when a clatter arose from behind me. There was a large group of what appeared to be highschool aged kids.... there were at least 50 of them surrounding my Elephant Seal observation deck. (Most of the Seals kept on sleeping, rolling and snorting away... paying no attention.)

I, on the other hand, wondered what the heck all these kids were doing here.... When all of a sudden, I cracked a smile in excited realization. I also chuckled a bit as I watched some dumbfounded people and their even dumber looking reactions to the newly created statues in the middle of the widest sidewalk in Waikiki.

I had seen this on the internet, maybe I-am-bored.com, or ebaumsworld.com, but either way, it's pretty cool. The first time I'd seen it done, it was in Grand Central Station, and involved a few hundred people I believe... however many it was, they were the majority in the station.

In Waikiki today, it was on a smaller scale, but cool none-the-less.

The students had just a moment before been chattering and milling about, around the sidewalk, into the grass near the palms, onto the beach... not straying too far from eachother, when all of a sudden, with seemingly one conciousness, they froze. They froze in whatever position they were in: mid-sentence, mid-step, in the middle of double-knotting a shoe, talking on the phone... whatever, they froze. Statues.

Baffled passers-by spun slow circles, gawking at the frozen clan as they navigated through the scene that was somewhat reminiscent of Pompeii (without all the death and destruction.)

I laughed at them for looking befuddled.

And just like that, sixty seconds later... they all, as one, continued on.... finished their sentence, hit their stride, tightened that knot, and continued that phone conversation. All of it, like nothing had happened, like time hadn't stood still for them.

turns out it was something like "take 60 seconds to think about big tobacco" it was an anti-smoking campaign... and boy howdy, it wasn't lost on the crowd. After they had frozen and reanimated, they eventually came back and handed out anti-smoking flyers... not a minute later there were six people within spitting distance of me smoking.

don't think the campaign worked, but the display of human art was cool none-the-less.

oh... and on a completely unrelated note, I got to use the phrase "toxic megacolon" in a real discussion today with a patient.... he had the megacolon, just not toxic. cooooooooool.

Attracting unwanted attention

Usually, one of the best parts of my workday doesn't happen at work at all. I'm about to make myself sound like, and feel like, that 1st grader who when you ask him, "Hey Charlie, what's your favorite subject in school?" and the little scamp replies "Recess!" or "Lunch!" Well, that's me. I like lunch the best-est.

Don't get me wrong, I feel like I'm learning something new every day here at the clinic, and everyone is great, from MA's to PA's to the doctor. It's nice to get to work with 2 Pacific grads.... smart folk they are. Anyway, that said.... I like lunch. See, I'm in Hawaii, but I work long days, (like the rest of you) and I don't get much time during the week to actually BE in Hawaii... but at lunch.... OHHHHHHHH at lunch.... I get to go to the beach, grab a seat, and enjoy my lunch. I start to relax, I watch the waves crash in along the white sand, (and I relax a bit more.) I watch the sailboats slowly pass along the horizon.... (getting more comfortable...) I watch surfers ride the waves as they track to the shore... (could almost fall asleep.) I watch the girls walk by in little bikinis... (am I in Heaven?) I watch a homeless man walk towards me and sit down across the table from me, and begin to me stare me down.... and I rel... wait, WHAT?!?!

I snap out of my dream-like state, with a "huh"... thinking "buddy! you're blocking my view." He says something about getting out of the sun, and I reply with something stupid like, "I hear that."

Oh no... I've opened the door to conversation.

Now, please, it's not that he's homeless that I don't want to talk to him, if he were rich, I'd be just as upset. It's that he's ruining my favorite subject; lunch. I think the only guy that I would've enjoyed talking to then, (that I don't know and love already) would have been Vince Vaughn, or Chris Farley (if he were still alive) or Will Ferrell... but if you're not them, keep on walking. now if you're a girl.... that's a different story.

So, this guy, whose name I still don't know, begins to stare at me some more, and talk to me, slightly incoherently. And, well, I'm not happy..... but I'm not going to ignore him.... I may be rude and frustrated in my mind, (and on this "blog") but I don't act that way towards him.

I'm a pushover.

So I start talking to him....

"How long have you been here?" says the guy.
"About 2 weeks.... 5 more to go. I'm working at the Waikiki Health Center for school."
He looks puzzled.
"Like a medical internship," I say.
"Ohhhhhhhhh." he sighs.
There is a glint of understanding and a flash of something that tells me I've opened up a can of worms

Nuts! this guy aint leaving.

He proceeds to tell me all about his medical problems, and the problems he faces in getting care. (which is sad, and a comment on our medical system. But much of it too can be attributed to this guy himself.) I find out he's a Navy Veteran, 60 years old, and moved from Chicago 3 years ago without a penny, or a plan. He doesn't talk to his family, he thinks that his brothers don't care about him at all. He doesn't want to go the VA because he thinks they don't know anything, he doesn't come to the Waikiki Health Center because he said that they turned him away (which they don't do there.)

He starts showing me the scabs on his hand... the scars on his ribs and so on and so forth.

Meanwhile, I'm plotting my escape....

He rambles on and on...... and on.

I look at my watch.

I miss my quiet lunch... i miss the waves, the waves, the girls. I feel like I'm at work! Is this guy really about to show me this lump on his butt? I'd be HAPPY to see this guy in the clinic, but not at the beach... I'm not sure that this is appropriate, or legal...

I look at my watch again.... YES

"Oh, LOOK at the time..... I've got to go, next patient is in 10 minutes. It was nice talking to you." (Lie.) sorry God, and Mom... But, it was a little white lie. and I WAS terribly polite, and talkative... he'll never know I was frustrated with him. but oh, I was.

So anyhow... i was left wondering two things.....

1.) Was my compassion only limited to the clinic, or was I maybe just having a bad day?

and

2.) Should I take the Thumper approach, "If you can't say anything nice (and in my case, mean it) don't say anything at all."

and the answer is.... I don't know.
all i know is that i missed my quiet, relaxing lunch today.

-pray for my humanity-

cn

They blow things up here too, it is America...

Some pictures from the 4th....

My impression of a tomato...

Today I'm laying low.

I can't say it's because I'm sick of the beach yet, or because I've mastered surfing, or because it's terrible weather outside. Nope. It's because my belly looks like a tomato. Or maybe it looks like I had a run-in with a bully who favors the "pink belly" as his form of torment. Or, for those of you who remember, it's reminiscent of the day a few summers back that I lost the fight with the pine tree and plummeted, belly first, into the Mississippi. But whatever the analogy, I'm like a human furnace, or, my stomach is. It seems that somehow the rest of my torso was spared. So, my stomach alone is putting out heat like a blast furnace. It's funny how quickly it heats the cold shower water (because I can't tolerate any warm water) into a very steamy hot-tub-like liquid that I can't take. It's actually pretty incredible. I think there's a good chance, maybe slightly more than 50/50, that you could fry an egg on my stomach, though it would taste terrible I imagine, due to the copious amounts of aloe I've been slathering on. I guess what it boils down to is that a very white guy like myself needs something greater than SPF 15 if I want to spend and hour and a half in the sun, at least until I get a bit of a base.

Woe is me....

So here I am, on an island surrounded by beautiful beaches, cobalt blue waters and waves fit for surfing.... and I'm sitting on the Lanai (hawaiian for porch) out of the sun, away from the beach, nerding around on the computer, trying to get some schoolwork done. At least I'll have a week here after my rotation to see the island.

So I thought I'd create this 'blog' (wow, i hate that word) so I could keep you updated on my vagrant year. Should have done this earlier, I know, but better late than never I suppose. So, let me give you a bit of a recap on my year so far.

First rotation; Circleville Ohio, ER.
-I sutured more than a couple of people up, and found 3 was the magic number. It took 3 times before my hands stopped shaking. "Oh no, me, nervous? No, no...no, I've done this many times, just had a bit too much coffee. Night shift, you know...."
-80% of visits aren't emergncies....
-Really like not having to chart ANYTHING
-Very much enjoyed the ER

Second rotation; Waikiki HI, Internal Medicine.
-It's warm here, and I'm very white.... need to take the sun thing slowly, (much more slowly.)
-Need to think of the big picture, not just 'treat and street'
-Wow, I'm really missing the times when I didn't have to chart

I'll keep you updated on the rest 'as it happens.' But for now, I need to re-apply another layer of aloe.

Peace in,

CN