Medicine – Page 5 – CA Work Experience Program

Day 6 at Waverly Hematology-Oncology

June 4th, 2019

Dr. Graham came back from the annual ASCO (American Society of Cancer Organization) in Chicago, so I shadowed him throughout the day. I learned a lot from Dr. Graham today, so I’m going to share some of this knowledge. In the morning, around 9:30, Dr. Graham received a call from one of his patients currently undergoing chemo and radiation. She called to inform him that her temperature was 100.4 °F. The patient is more susceptible to illnesses because this regiment reduces her white blood cell count in half, and her current temperature can dramatically increase to 104 °F in less than an hour. Dr. Graham pondered about her situation and told her to come to his clinic instead of going to the ER. Despite his packed schedule, he told her he’ll be able to accommodate her in his day. Dr. Graham hung up the phone and explained me that because her health records were fine and she just had a mild fever that he saved her from paying $3,000 – $5,000 for an ER visit compared to $150 – $200 for a clinical visit. In these types of scenarios, you have to consider the severity of the patient’s situation and more importantly the cost of going to the ER vs. going to the clinic. Had the patient’s situation been much worse, Dr. Graham would have advised her to go to the ER, no questions asked.

One of the hallways inside the Waverly Hematology-Oncology clinic

Day 5 – Meeting More Patients in the Hospital

Today had a very similar schedule to yesterday. There were several procedures that needed to be completed (although there were less than yesterday) before Dr. Lawal took me around the hospital. Most of the procedures in the morning were EGDs which are a shorter procedure (around 10 minutes) compared to the colonoscopies (around 25 – 30 minutes). One of the patients had extensive family history of colon cancer, so extra careful study of the colon was done. One of the polyps that was found is called a pedunculated polyp, which is a polyp that has a stem that connects to the lining of the colon. I have an image of this polyp attached.

Afterwards, we visited a few patients in the hospital. The first was an alcoholic who was beginning to develop complications in his liver. With extensive drinking, the liver, which detoxifies blood and the body, begins to fail and stop working optimally. This patient was experiencing this and had extensive water buildup in his abdominal area. There were around several liters of water that needed to be drained. Also, with dysfunction of the liver, water begins to buildup in the legs of the individual. This can bee visualized through pressing down firmly along the patient’s leg. If the depression remains, there is water retention. With continued abuse of alcohol, symptoms can worsen, even resulting in complete failure of the liver. Another patient we visited was having acute abdominal pain. Previous surgery had placed a stent that allowed flow of fluid from the pancreas to the small bowel. While the stent is supposed to fall out, this did not occur and there was considerable buildup of debris. This lessened the possible flow of pancreatic fluid to the rest of the body leading to pain.

Tomorrow, I will be doing this same thing, but I will be staying later so I can see more patients.

Day 7

The most different thing about today was a lunch meeting. Someone brought pizza for everyone and we all gathered in the lobby for a meeting with Jackie from a program called Reach Out and Read Carolinas. It already has over 300 participating locations in North Carolina, and is currently looking to work with Cary, Apex, and Fuquay-Varina Pediatrics to expand its reach. Reach Out and Read is a program implemented in pediatric centers that provides a free book to patients at every well check from six months to five years old. Dr. Villareal explained to me that providing enough books to all three locations would not be cheap, but that they ultimately decided to implement it for the benefit of their patients. I thought it would be a wonderful opportunity to both emphasize the importance of reading from a young age and provide families with books who may not otherwise have that opportunity. The meeting gave me some insight about expanding the office and its programs that I did not get otherwise in my daily shadowing of the doctor.

Additionally, I got to see a little more of the mother’s side in the newborn story. There was a mother who came in with a five-week-old girl. There were already some complications with the baby — she had had an infection in one of her tear ducts and had to stay in the hospital for a week. They had just been cleared from the hospital a few days ago and the mother was visibly exhausted. Her baby was crying the whole visit, and she explained that she was probably hungry because she hadn’t had a chance to feed her. When Dr. Villareal asked her how much she nursed per day, the mother pulled out an app on her phone and revealed that it was 8-9 hours daily. On top of that, the baby rarely took naps. She told the doctor that she had been going to a lactation support group but that they only found things wrong with every member and that it made her feel worse. Dr. Villareal assured her that her feeding schedule was perfectly normal and that she should continue doing what she was doing. I saw that pediatricians not only have to care for children, but also their parents. I’m excited to see what my last day at Cary Pediatrics has in store!

Reach Out and Read Carolinas infographic

Day 6

Today, the patients and cases we saw were quite normal, but it was the conversations out of the exam rooms that made the day memorable. The nurses and doctors are all pretty close, and act very much like a family: bickering and teasing each other incessantly. There was often lots of free times between patients, but the nurses kept it very fun! They like to call their clinic “the fun one”. We discussed where we would move in the future, many arguing for Arizona or Florida, and we discussed Minnesota accents, which they claim that Dr. Eisenbeis has.

One patient that stood out was this woman with smoldering myeloma that is not treated because it is not malignant, but it is like a ticking time bomb and could go off at any time, with no trigger. She was very on edge and nervous at first, but once the doctor said she was still fine, she calmed down. She stated that it is quite difficult to forget about her disease, even though she’s had it for almost 10 years, because there’s always a cancer commercial or ad. She even said that only her immediate family knows, because she doesn’t ever want to talk to relatives or people about it at family gatherings. At first, I didn’t understand her anxiety, but afterwards, I realized just how scary it is to live every day not knowing when you could contract cancer. After hearing so much about cancer for the past week, it seems almost normal or not as severe to me, but it is still scary and y predictable. It just made me realize how strong and inspirational those patients are.

Fun Facts:

According to nurse Melanie, you can have five wives in Utah and there are penguins in Alaska.
A phlebotomy is a procedure that removes blood to treat high iron levels or blood counts.
The UNC Rex Hemonc Clinic in Cary is the fun office
For one patient, his wellbeing is gaged on how often and how well he plays golf.

Roles in the ER

Doctors
- Attendings
- Residents
Nurses
Physician assistants
Physician assistant students
Medical school students
Interpreters (Spanish)
X-ray & other technologists
Pharmacists
Scribes
Consults
- Psychology
- Neurology
- Gastroenterology
- General medicine
- Oncology
  - Liquid tumor
  - Solid tumor
- Thoracic surgery
- Vascular surgery
- Internal medicine
- Radiology
- Hospitalists
- Neurosurgery
- Renal
- Orthopedics
- Ophthalmology
- Physical therapy and rehab
- Social workers
- Outpatient resouces
- Poison control (via phone)

Example of someone receiving an x-ray from an x-ray technician (I saw this process occur for a chest x-ray)

https://alis.alberta.ca/occinfo/occupations-in-alberta/occupation-profiles/combined-laboratory-and-x-ray-technologist/

Poison Control- a helpful resource for the ER

https://www.aapcc.org/

Learning days at Cary Dermatology!

Completing modules fashioned for med-students on 2 or 4 week rotations teaching about the basics of Dermatology.

Today I joined Hannah G. at Cary Dermatology where we complete our regular rounds of alternating going into a patients’ room with Dr. Mangelsdorf. Hannah and I talked a lot about all the different things we’ve been doing for the past few days that we hadn’t seen each other. I told her about the Mohs’ surgery that I witnessed, and she told me about the new information she learned through the teaching modules from the AAD. It was fun to start the day at 1:00 so the day went by very quickly. Hannah and I saw patients with psoriasis, warts, dysplastic nevus (atypical mole) and more. Besides that, we saw most of the same things I saw the first week I was there. It was really nice to be working with her as well as continue to reinforce my understanding of all the dermatology terms I have learned until this point with Dr. Mangelsdorf and the nurses throughout the day.

Day 6– Duke Work Experience

This morning, I started my day in the stem cell lab, watching the thawing of MSCs (Mesenchymal stem cells) for a trial that the department is currently doing. The thawing took around thirty minutes, although the actual work with the cells only took around 15 minutes. I learned that after testing the sample for viability and number of cells, multiple signatures were required to allow for it to be infused into the patient. These cells did not take as much time to thaw as the cord blood cells because they only require dilution before being ready for infusion.

This was the image for the test for cell count– Live cells versus dead ones

This was the final product in the lab, all they have to do now is sign the papers

In the afternoon, I shadowed Dr. Kurtzberg in the outpatient clinic. Most of the patients were here for follow-ups and a couple had been transplanted many years ago. It was wonderful seeing Dr. K interacting with her patients, many of them who now have had her as a doctor for many years. The check-ups mostly involved asking patients questions about their latest concerns. I learned that asking the right questions to get the answers that a doctor needs is very important. While today was my last day in the clinic, I will be able to learn more about the more technical side of medicine in the next two days.

Day 5 at Waverly Hematology-Oncology

June 3rd, 2019

Dr. Graham was still at the annual ASCO (American Society of Cancer Organization) conference in Chicago, so I once again shadowed Ms. Vanessa, one of Dr. Graham’s Physician Assistants. Ms. Vanessa had a relatively relaxed schedule today with only a few patients to see for their regular check-up. However, she did have three Chemo-Ed sessions with patients who have three different types of cancers, so she let me sit in on the meetings. For those you don’t know, Chemo-Ed sessions are meetings where the patient and their family meet with the doctor to discuss the timeline for treatment, the different types of drugs/radiation that will be used, side-effects of the treatment and any other questions in general about this whole process.

Treating cancer is very difficult, but with all the advancements made in science and medicine, most types of cancer are curable which is a testament to the amount of progress we have made in the field of oncology. The regiment, as the doctors call it, included using chemo and radiation to shrink the tumor and remove any remnants of it through surgery. The patients were so kind and cheerful and maintained a smile on their face throughout the session. It was amazing to see how much courage these patients have to be able to undergo such intense treatment as chemo and radiation. Ms. Vanessa was so cordial throughout the session which made the patients very receptive to all of her advice about the treatment plan. The Chemo-Ed sessions concluded with a brief conversation with AJ, the insurance coordinator. It was a very gratifying feeling when AJ said 90% of their treatment will be paid by their insurance which only 10% will be paid by the patient’s family.

Through my five days of being at Waverly Hematology-Oncology clinic, I have noticed that being in the field of oncology is extremely challenging. Cancer has earned a reputation over the years of being particularly difficult to treat, which it is, but with all the advancements made in the field of oncology, more types of cancer are now treatable with little to no chance of resurgence, which is absolutely amazing!

The Infusion Room for the patients undergoing cancer treatment and their family

Tergus Day 2

Today, we were with a specific lab group, the IVRT, or the in-vitro release testing group. As the name suggests, this research team aims to discover whether a topical substance can penetrate the skin, and to what degree. Although dead skin samples from frozen cadavers are used to stimulate real skin, a different section of the IVRT department utilizes real skin cells for skin irritation testing. In skin penetration testing, glass pipe-like devices constantly circulated with distilled water are utilized to simulate the bloodstream, while a t hin slice of skin is placed to cover a hole above to simulate the skin’s many layers. After testing, the different skin samples, which can be up to a sample size of 90, the different layers–dermis and epidermis–are sectioned off to see if the drug was released into the layer, if at all.

Later, we shadowed as the lab technicians performed some mundane–but highly important–tasks. For example, every action, from cleaning the glassware to how much of a chemical was used, was meticulously documented in a lab notebook. Brandon, our guide for the day, told us that there hasn’t been any accidents so far–for example, the emergency showers have fortunately never been used so far. To me, it seems as if these safety procedures have been extremely effective.

I experienced both the science and the not-so-science sides of labwork today, which gave me lots of insight into the lab procedure. I look forward to the remainder of the week.

ED Observation: Daytime

Day 2 of shadowing Dr. Limkakeng in the DUH Emergency Department began with “check out,” where doctors and physician assistants from the previous shift shared information about the patients that would carry over into the next shift. Dr. Limkakeng then got started with the observation unit, where he checked in on a patient suffering a Sickle Cell Disease pain crisis and admitted two patients into the hospital: a woman with a severely infected insect bite and a 90-year-old patient who was still in bad shape after a stroke.

Then Dr. Limkakeng took me to see the psychiatric ward of the Emergency Department. To run it, there is a whole psych team with doctors, a PA, nurse, and pharmacist along with security personnel. Everything is bolted to the ground to prevent suicidal patients from harming themselves, and there are plenty of cameras throughout. Some patients can spend up to days in the psych ward. Today the ED ran into a bit of a dilemma due to a bed shortage in not only DUH but in North Carolina in general. This was made even worse by the fact that the psych ward was undergoing a short-term construction project. There were many psych patients taking up ED beds, and many patients that needed to be admitted taking up ED beds with no beds for them to be admitted to in other departments. Therefore, the waiting room was building up too, and the hospital started diversion for a few hours. However, I still got to follow Dr. Limkakeng around as he saw many patients nonetheless.

The next patient was understandably very concerned by the fact that she could barely move/lift her arms. She also had a high white blood count (an indicator of infection), so an emergent MRI was ordered due to the possibility of pressure on the spine. However, Dr. Limkakeng showed me the MRI and how it didn’t seem to show any abnormalities around the spinal cord and CSF. The MRI was taken from multiple angles so results could be seen more clearly.

Another patient came from EMS during the night. He had consumed a lot of pills, but his symptoms had mostly subsided besides diplopia (double vision), so he mainly just needed a psych exam. Next was a patient with septic shock and hypotension. Dr. Limkakeng is doing research through a clinical study directly comparing more fluids and more medication as treatments for hypotension. The patient had a history of drops in blood pressure, so Dr. Limkakeng got him enrolled for if it became low enough for the study. Treatment is the main priority of course, but the randomized treatment that the patient would end up with would be fluid bolus.

While still in the resuscitation part of the ED (called “resus”) where the hypotension patient was, I was able to observe a patient with ventricle tachycardia. The hallway was cleared and all the doctors and nurses were very serious in preparation for his arrival, but when the patient came, he was not in cardiac arrest. Despite ventricle tachycardia he was not even experiencing chest pain! Everyone was quite relieved, but they still monitored him, asked questions, gave warnings, and drew blood.

After that was a woman who was discharged, but an appointment was made for a stress echo cardiogram to try to find the root cause of her worsening chest pain. Next door was a man with asymptomatic bradycardia, or low heart rate. He was also discharged and would later call his cardiologist. Later, a patient came in due to cachexia. He was sadly experiencing failure to thrive (weight loss, weakness, not eating) due to esophageal cancer, and while he wasn’t able to get a treatment in the ER, he was at least able to consume some saltines and peanut butter.

The next patient had what Dr. Limkakeng and his colleagues presumed to be some sort of food poisoning because of the acute nature of the symptoms. He was given a medicine to coat his stomach in pepsin, and Dr. Limkakeng decided to treat him symptomatically. One of the last patients had mild hypoxia, meaning there was not enough oxygen in her body tissue. In this case, it was due to Leukemia (already diagnosed before ED visit), so the liquid tumor specialists of oncology were consulted. Finally, as the shift ended, Dr. Limkakeng decided to send a lung cancer patient to resus because of their tumor, hypoxia, high white blood cell count, low sodium and high calcium. Sadly I had to leave at 3:30, but Dr. Limkakeng was going to do a pelvic exam on a patient as I left. He also never took a lunch break! Unsurprisingly, I left the ED feeling thankful, inspired, and ready for more shadowing next time.

Average wait times at DUH ED according to ProPublica

https://projects.propublica.org/emergency/hospital/340030

Example of an MRI showing the spinal cord and multiple views

https://www.ucl.ac.uk/healthcare-engineering/events/2019/jan/spinal-cord-mri-workshop