Medicine – Page 4 – CA Work Experience Program

Night Shift 2/2

Today we hit the ground running once again! As soon as I got to DUH, the first patient of the day had intense pain and irritation/scratching from his contact lense, so Dr. Limkakeng examined his eye. Next was a patient who dislocated his shoulder for the third time. An xray was ordered and the patient actually popped his shoulder back in himself, making life for the PA just a bit easier. Dr. Limkakeng showed me the difference between the normal shoulder xray and the dislocated one, told me about how tendons become weakened/loosened/injured, and explained a few different methods of shoulder reduction. He secured the patient in an immobilizing sling to wear until he got a follow-up.

One of the more complicated patients of the day was a woman with congenitive heart failure who presented with low blood pressure and high potassium (hyperkalemia). With her left ventricle not functioning well, Dr. Limkakeng noticed water in the lungs (shortness of breath and heard in exam). He drew me a diagram showing me a simplified version of how IV fluid enters the blood to the heart and lungs and how too much IV fluid could actually be harmful to this patient even though it is a way of increasing blood pressure. The patient seemed to have acute kidney insufficiency and I think she was admitted to the hospital.

A cool learning moment was when Dr. Limkakeng was showing me an EKG and explaining parts of it. EKGs have a lot to do with action potentials and sodium-potassium pump, which are things I very recently learned about in Adv. Biology. Finally I kind of understood something! 🙂 I also got to see a translator in action, as one of the patients only spoke Spanish. The translator was very experienced and explained movements and a few details of the simple procedure without being directly asked. It was a bit more fluid than completely word-for-word.

Dr. Limkakeng also splinted a finger (smashed in a metal gate) and saw several other patients, but the most serious medical procedure of the day was suturing a wound. A patient had previously had plastic surgery and then fell into her dresser and split open her chest. Dr. Limkakeng and the PA student thoroughly irrigated it with water, injected a syringe full of pain medication, and used 2 deep dissolvable sutures and 10 external sutures to close up the wound.

Example of an x-ray of a dislocated shoulder

https://radiopaedia.org/articles/shoulder-dislocation

Example of an ECG

https://www.ndsu.edu/pubweb/~grier/1to12-lead-ECG-EKG.html

Day7

I am heartbroken to say that today is the last day I will be shadowing the doctors officially, for there is a fellow and resident graduation on Friday. However, today was one of my favorite days as Dr. Carlson brought in his homemade smoked wings to the office. My morning started with setting up the camera and the computer screens and shadowing Dr. Carlson. Today was somewhat of an easy day as there were not as many patients in the clinic, meaning we took long breaks during each patient. Dr. Carlson and I talked about sports and compared the college applications from more than 50 years ago to the current ones. I also congratulated him on the 38th anniversary of his first date with his wife. After meeting with about 15 patients, the entire Cornea group had lunch in the conference room eating Dr. Carlson’s wings, which were amazing. Then we went to the OR doctor’s resting room and handed out the chicken. Afterward, I was shadowing Janet again in Ocular Immunology Center. Today with Janet, I helped her set up special vision tests and watched her take out healing lens. I was sad that this was the last day for me at the clinic, and I am grateful to have this opportunity.

Day 6

Today, I spent the entire day at the Ocular Immunology Center, where there are more serve cases. The Cornea clinic would see patients that have cataracts, clouded capsules, fungus infections, and similar cases while the Ocular Immunology Center would see the more “gruesome” cases. Eyes that have previous damage or special conditions would get checked in the Ocular Immunology Center. The patient process is similar to almost the same as the Cornea’s process. First, the patient will check in at the front desk. Next, the patient will be checked up by a technician, then a fellow, and finally by Dr. Perez. After shadowing Dr. Perez for two patients, I wanted to follow a different technician around the hospital. Thus, I followed Janet for the rest of the day. Her job in the clinic was different from the other technicians as Janet would actually run around the hospital, getting prints and entering labs for results and cultures. I definitely was glad that I wore my tennis shoes because following her was not easy. I ended up in the OR to pick up cleaned instruments as the last job of the day. The experience at the Ocular Immunology Center was a completely different experience from the past week.

Day 5

I was at the Cornea Clinic today, and all day long, I was following a Cornea fellow. There was nothing out of the unusual today other than meeting with Dr. Kim later. During the day, the cornea fellow taught me how to set up the computer program which connected the camera to the screen. In some rooms, there are learning scopes attached to the lens and in some rooms a camera to the lens. So, when we are in rooms without the teaching scope, I connected the lens to the screen, allowing me to look into the eye besides the fellow. Interestingly, the older doctors such as Dr. Carlson do not know how to work the program; therefore, before the rotation starts, I would go into each room and set up the screens. I meet Dr. Terry Kim, the current head of Ophthalmology, in a conference room and learned about cataract surgery at the end of the day.

Day 7 at Waverly Hematology-Oncology

June 5th, 2019

Today was a very exciting day for me from the perspective of gaining knowledge. In the morning, I was able to witness Ms. Susan (Dr. Graham’s Physisican Assistant) perform a bone marrow biopsy in order to obtain a sample of bone marrow tissue to evaluate the different types of blood cells as well as the structure of the bone marrow. Ms. Susan showed amazing composure as she numbed both in the outer and inner layer of the skin before inserting the needle through the skin and into the bone to obtain a sample of the bone marrow. I was amazed by how quickly and accurately Ms. Susan performed this procedure which lasted only 10 minutes from start to finish. The patient was numbed well as she didn’t seem to feel a 5-inch needle being inserted into her body as she continued to have lively conversations with Ms. Susan. The patient was also extremely fit, which meant her bone structure was superior to other patients her age, making the bone marrow biopsy a little more complicated, but nothing Ms. Susan couldn’t handle! The procedure ran smoothly and the patient was very appreciative that they told her to lie on her back so that she didn’t witness a giant needle being inserted into her body. Ms. Susan also praised me for being able to witness the whole procedure without passing out, claiming she had seen far too many high school boys pass out on her while she performed the bone marrow biopsy.

Afterward, Dr. Graham took time out his schedule to sit with me and chart my family’s pedigree to determine my risk of cancer. I had learned a little bit about crafting family trees in 9th-grade Biology (shoutout to Dr. Bartling)! Dr. Graham gave me a quick crash course on Genetics just as a refresher and explained how they create pedigrees for every single patient in the clinic. Then the focus switched over to Dr. Graham’s expertise: breast cancer. He introduced me to the Gail Model also known as the Breast Cancer Risk Assesment Tool which uses seven different variables to calculate your 5-year risk and lifetime risk of breast cancer. Here is the link to the risk calculator from the National Institute of Cancer to check out: https://bcrisktool.cancer.gov. Then, he told me about a very famous study conducted in Houston from 1992-1998 to determine the accuracy of the Gail Model. They took a group of women ages 35-78 and divided them into two groups. One group received the placebo while the other group received Tamoxifen (a very popular drug to treat breast cancer and even prevent it). The Gail Model predicted that out of the 6,700 patients receiving the placebo, 176 would get breast cancer and the actual number was 178. For the 6,700 patients taking Tamoxifen, the Gail Model predicted half as many to get breast cancer with an estimate of 89 and the actual number was 87. This is why the Gail Model is one of Dr. Graham’s favorite tools to determine your risk of breast cancer.

I learned so much today and can’t wait to see what’s in store for tomorrow!

Dr. Graham explaining me the Gail Model experiment

Last day of Work Experience:(

Today was my last day at Cary Dermatology as well as the Work Experience. The WEP has been pretty fun as I feel i have gotten more out of the journey than I expected. Yesterday Hannah and I went into a surgery for the last time with Dr. Mangelsdorf. We captured our last moment by making a funny video of us taking off our protective equipment (known as PPE). All in all, the experience was fun because I really got to bond with people in two different places. Southern and Cary Dermatology really opened my eyes to what the work world of Dermatology looked like and I really enjoyed it. To all the doctors, I really appreciate them letting me learn in the midst of their busy days.

Day 8

My last day at Cary Pediatrics was a great close to my work experience. Dr. Villareal’s first three patients were all teenage well checks, so he let me shadow one of the phone nurses, Jenni, instead. I learned that it’s one of the crucial jobs that most people don’t even realize exists (I certainly didn’t before my time at the office). When I thought of “nurse,” I had always pictured someone in scrubs taking measurements of and giving shots to patients, but I discovered that phone nurses are the foundation of support for patients calling in about practically anything. Jenni worked with incredible accuracy, detail, and speed to replay messages left by parents, take notes on their content, peruse the patients’ medical records, call back parents and/or pharmacies, and take further action if needed (whether that was writing a note to the doctor, suggesting a home remedy, or scheduling an appointment). One of the most important parts of her job is telephone triage, which essentially means making a decision on when to see the patient based on calls describing their symptoms. It’s tricky because the nurse can’t physically see the patient but must decide how severe their case is; the procedure is to go down a list of yes-or-no questions decreasing in severity of present symptoms. At the first “yes,” the nurse directs the patient to follow that category of urgency, ranging from home care up to calling emergency services (see attached picture). Jenni told me that she had been doing it for so long that she had basically memorized the questions to ask for common symptoms such as a sore throat, and an online program helped in cases of rarer symptoms. It was eye-opening to see a usually hidden or disregarded side of pediatrics at such a close level.

Additionally, there is at least one interesting story every day; today was no exception. This appointment was actually a Spanish-speaking one, so Dr. Villareal had to explain everything to me afterwards. Long story short, the family had gone to an alternative medicine doctor in Winston-Salem who claimed she could cure autism and was requesting urine and stool samples for their six-year-old boy. This case showed me yet another aspect that doctors have to deal with: false advice or differing views that could turn a patient’s opinion against them. Practicing medicine is so much more than just learning the textbook inside and out; I’ve seen time and again now how flexibility and good communication skills are just as vital to the job.

Ultimately, I’ve really enjoyed my time here at Cary Pediatrics, and I’ve learned so much more than I had anticipated. I’m thankful for the wonderful opportunity I had to shadow Dr. Villareal and the other staff, and I would highly recommend anyone who likes pediatrics, medicine, or kids to try it out as their work experience!

General chart used for triage (in practice, it would have specific questions listed for a particular symptom)

Day 7

Today was my last day at the hand center, and it was very event-filled. We saw a lady with a finger wasp sting, quite a few carpel tunnel syndrome patients, some shoulder injuries, and endless trigger fingers. Dr. Schricker showed me a picture of a surgery he performed a few days ago where he took out 62 pieces of bone and cartilage from a man’s elbow. 62! Some were the size of a peanut and some were upwards of 2-3 cm in diameter. It was crazy, and it was pretty rare for the doctors there as well. The x-ray was something I had definitely never seen before.

One sad moment today was when a older lady started crying because she didn’t want to lose the use of her hands she had been experiencing pain and no one knew why, and she started crying. Her husband was trying to cheer her up saying how she had perfect blood pressure, needed no medications and was in tip top shape. It was very cute! Made me realize how scary doctors offices can be, especially if the doctors don’t know what’s wrong either.

Another highlight was that one of Dr. Schricker’s patients made filipino egg rolls for the entire office staff, beef and veggie, and pork, and they were delicious! I need to find the recipe somehow because those were some of the best egg rolls I had ever eaten. At the end of the day, it was time to say goodbye and I was kinda sad because everyone was so nice and I really had a great experience with them. I hope to visit again someday, but hopefully not as a patient!

Fun Facts:

Dr. Schricker has climbed Mount Kilimanjaro.
Wasp stings take over a year to heal when in the finger.
Turmeric is shown to help arthritis.
A man was launched 21 feet in the air from his motorcycle, and swears he will never get one again. Motorcycles are scary.
The Raleigh Hand to Shoulder Center has the best nurses and doctors.

Day 6 – A Break from Service

Today’s schedule was more similar to last week than any of the days this week. This was because Dr. Lawal had many procedures today. There were so many cases that my day ended more than an hour and a half later than usual. This can also be attributed to two cases which took quite a while longer than expected.

The first of these two cases involved an individual who had taken a Cologuard test. This is a test tjat can be administered at home that indicates (with great accuracy) whether you have colon cancer or many polyps or not. This individual had received positive feedback from the test, hinting at the possibility that the individual has cancer. While colonoscopies normally take around 25 minutes to complete, the colonoscopy of this individual took an hour. This was due to the extremely high prevalence of polyps: a total of 23 were removed and even more were left untouched (since they looked hyperplastic). Luckily for this individual, there were no cancerous growths; however, rhe individual will need to return in 1 year to get reassessed.

The second case that caused delay was an EGD of a very old individual afflicted with dementia. The issue involved the transfer of anesthesia to the patient. The problem was eventually found to be involving the IV. It took 3 attempts to place an IV so that it was functional and after that the operation proceeded smoothly.

Tomorrow I will be staying late once again. But, I should be able to see more patients in the hospital tomorrow since Dr. Lawal has a lighter procedure load.

Above are images of equipment and diagrams used today.

Day 7– Duke Work Experience

Today was the first day of the GMP FACT inspection. Therefore, I was in the North Pavilion building for most of the day. Throughout the day, the inspector would go through the lab, making notes of what the lab did or didn’t do correctly and evaluating the various documents that a lab is required to have. The day started off with a general introduction of the lab, which Dr. K presented and an overview of the staff associated with the lab. They then moved on to the storage units where they keep supplies used in the lab and made sure that labels were correct, as well as whether the temperatures and humidities were fine for each room. In the room with the liquid nitrogen tanks, the inspector made sure that the safety of the workers was handled well and that the FDA had approved the tanks for use. They then moved on to the sterile part of the lab, which I did not participate in.

This was one of the liquid nitrogen tanks used to store cells in. It is similar to the one that I saw on Day 2.

I instead went with Dr. K to visit radiology in the main hospital. There, we reviewed a patient’s MRI from the day before because there had been some inconsistencies. I was able to learn the different ways the readers could manipulate the images so that they could get a clear picture of every part of the brain. After I got back, I learned the process of which charts are filed in the office. One of the assistants of Dr. K showed me how to write letters to the patient informing them of their next appointment and how to update patients’ charts online. I then was able to attend a Skype meeting with a patient who had recently developed strange symptoms. I listened in on what the family’s pediatrician could do to help the child and how the family should monitor the child. To wrap up my day, I attended a meeting discussing the details of the current clinical trial.