Final Days

I'm finally back home and it feels sooo good to sleep in my own bed and wake up with Ryan right next to me again. I can't believe it's here, graduation is only 8 days away and it's a little unbelievable right now. The next week I'll be in class, which is going to be a tough transition I'm not really looking forward to 8am - 6pm sitting in a chair again. Especially since I know first thing right off the bat is a test... uggh. But that is the next phase for me, studying for the PANCE! a 5 hour test broken up into 6 60 minute blocks testing me on 13 systems and roughly 20 different diseases in each system. YEAH super looking forward to that.. Well at least I'll have a few weeks to study after graduation. Oh and I have to find a job in the mean time as well. Sometimes it all feels a little overwhelming. But first things first GRADUATION, woooo hoooo!

Endurance...

My endurance is waning, not for working, just things like laundry, ironing, Patient tracking, EBM and H & P assignments and... well..... blogging. Sorry but I feel like here towards the end it's more important to spend my very precious, because there is so little of it, free time doing what I think is truly important. For example studying for the PANCE which I am now officially registered for! And reviewing anatomy and procedures for my current rotation... which I am LOVING!! Yesterday I helped do the most fantastic I & D in the OR. A patients ventral hernia mesh had gotten infected ( for the 3rd time ) so we opened up her belly and drained.... wait for it.... 3 Liters of PUSS!!! It was gross and foul smelling and AWESOME!! I loved it!

Out of Africa!!

Wooo Hoooo! I made it! I'm now safely back on American soil, and have never been more thankful to be a citizen of the USA than I am today on this beautiful 4th of July.

I now reside in the pleasant little town of Ashland OR, where the weather is warm and the people are too! I just finished my first week at the clinic and am gearing up for week 2, but it's late and I'm tired so off to bed I go. I'll catch up with a review of my days here sometime this week. Until then.... remember to eat lot's of fiber, your colon will thank you :)

Week 4

On Sunday Le, Tammy and I decided to go for an adventure with George (Alice the Anesthesitis’s “brother”. Actually I just realized I haven’t talked about Alice yet so allow me this tangent to tell you a little about her. She is fantastic and I love her!! Alice is a Clinical Officer, Kenya’s equivalent to a PA, who did further training to perform anesthesia and has been working at St. Josephs for 5 years and Homa bay district hospital for 1 year, she is extremely busy. She lives next to our house in the hospital compound and was one of the first people to welcome us when we first arrived at the house. She has been extremely helpful both at the hospital and with cultural issues here in country. Last week she invited us over for a glass of wine and her favorite soap opera, which she is obsessed with! While we enjoyed a wonderfully cold glass of South African white wine, we met her “brother” George, cousin veronica and actual brother Jeffrey (who also works at the hospital in maternity and is amazing with mothers in labor, fun to work with and in general another one of my favorite people) George and Alice talked about some places they thought we might enjoy visiting that are nearby. Thim leech, Ruma national park and Gogo falls and we made arrangements to go with George the following Sunday to visit one or two. In short Alice is one of my favorite people here and meeting/spending time with her has been another highlight of the trip). Now to continue with my story….

So George helped us arrange to rent a matatu for the day and accompanied us on a trip to Kisii which is famous for its soap stone carvings and then on to Ruma National park, which is home to elephants, giraffe’s and many other animals. The trip was, which I’ve grown accustom to, difficult from the beginning. The drivers of the matatu decided that the price of driving all the way to Kisii and then to Roma (which are in opposite directions) was too far for the previously agreed upon price of 8,000ksh (94$) so we had to negotiate a new deal which included paying for the petrol. After some haggaling we agreed upon 11,500ksh (135$) for the whole day rental of the matatu. We spent 1hr ½ in Kisii looking through the many shops and buying up beautiful souvenir bowls, chess sets and vases. After our shopping spree we piled back into the matatu and headed to Ruma. We stopped in a small town to pick up some lunch, well the drivers picked up lunch we had packed snacks. Lunch for the drivers consisted of a loaf of bread and a pouch of milk (no cartons here). We shared our peanut butter Cliff bar with the drivers. It was pretty amusing to watch them take such a small bite at first and then gobble up the rest of it. As we pulled into town we noticed a long line of people in the street, as we got closer we saw the line was made up of children in uniforms all marching together. George explained to us the scouts were having a parade. Girls scouts, Boy scouts, Eagle scouts, Brownies there must have been 80-100 kids marching down the street. Then George told us he was a scout and we compared scouts in the states to the traditions of scouts here in Kenya.

The drive to Ruma was filled with sweeping green hillsides dotted with farms, tin and grass hut roofs and some unbelievable views of the entire valley. After 2hrs of driving we finally reached our destination. Unfortunately we had been told the entrance fee was 200ksh, turns out that is the price for Kenya residents, the non-resident price is $20 USD!! We offered to pay the student price of 10$USD but apparently that only applies to students under the age of 23. And I realize one of Kenya’s primary draws for tourists is their parks and wildlife, so I understand the price. Unfortunately we are here as volunteers to help people in the area and I think with as many missionaries and volunteers as they get, it would be reasonable to also have a lower price for people who are here to work, not here on vacation with a ton of money to spend. So the fee would have made our trip a grand total of 65$ just for Ruma… After much deliberation and many failed attempts to negotiate with the park official, we decided it was just too expensive and turned around.

The rest of the week at St. Joe’s was pretty normal filled with the mundane, spiked with a few exhilarating, yet sad incidents. I rounded on the Medical ward with Dr. Megori, who is a great teacher and it was interesting to compare treatment plans, which most of the time were very similar. I got to see an AIDS patient with a classic manifestation of Kaposi Sarcoma and was shocked to see her CD4 count was literally 1! I had a few patients die, but unfortunately they were immunosuppressed and circling the drain, there was nothing more anyone could have done. Tammy and Alice had a very tough case this week, a small child of around 2yrs was brought in with severe burns over the face and upper extremities, after a successful resuscitation and careful management, she later died due to resources. Unfortunately the hospital doesn’t have an ICU for patients that need that high a level of care. What worse is that even if they did the child’s family doesn’t have the money to pay for it. One of the saddest things I’ve seen is the grandmother and mother of the child paced and wailed outside the hospital gates for 2 days mourning the loss of the child, but also begging for money to pay the hospital debt to release the body for a burial in the family plot.

On Wednesday we drove up to Homa Bay district hospital, where we toured the facility and participated in rounds. The district hospital is a government run hospital and the difference between it and St. Joe's is striking. The district hospital is larger, with more patients and worse pathology than St. Joe's. They are severely understaffed ( 2 nurses for 26 patients in the surgical ward I rounded on) and the drug supply is unpredictable. It is a teaching hospital though so the Doktari I rounded with (Dr. Elisa) had 12 clinical officer student with him, so he was an excellent teacher! After rounds we met with the principle and administrator of the CO school next to the hospital. After our tour of the school we drove down to Lake Victoria and had lunch at a hotel right on the lake!

We finished off the week in Bware where we were scheduled to meet with the BBEKAS group and BUCHWA. We arrived at Bware primary school as the venue for the meeting; however as with just about every meeting in Kenya there is the 2 hour window of when the meeting actually takes place. So we played with the children until the other headmasters arrived. Tammy organized a football game and Heather and I walked around talking with the kids. We met a teacher conducting a small group of children singing in the corner of the soccer field and the children sang the most beautiful little song for us. In speaking with the teacher we learned the group was actually practicing for a competition next week. It turns out they had already won 2 other competitions and were scheduled to compete at the provincial level, if they win they will go onto the national competition and winning there means the opportunity to sing for the President of Kenya!

Later we met with the headmasters of the primary schools and presented them with a form to track the health of their students over time. We also outlined implementation time line and the logistics of completing each step. We also met with the BUCHWA group and gave a presentation on female cancers, diabetes, hypertension and stroke. As well as conducted a workshop on taking blood pressures. We also toured the Bware dispensary and inventoried the items we brought as a donation.

Only 12 days left, 4 days at St. Joseph’s, 1 day in Bware, 1 day of travel to Mombasa, 4 days in Mombasa! 1 day of travel back to Nairobi and on Friday June 24^th we leave Kenya.

Pictures yeay!!

WEEK 3

This week we said goodbye to our new friends Cheryl and Lauren from Michigan. They are an amazing mother, daughter duo who joined us the first two weeks and it was pretty sad to see them go after everything we had experienced together. So we all went out to dinner at the Bliss Hotel, where we had a few cold beers, lot’s of laughs and a few tears, as they climbed into the taxi.
On Wednesday we got up early all 5 of us squeezed into a car with no seat belts and only 4 seats for an hour and half bumpy ride on our way to Kopanga dispensary. We’ve grown accustom to squeezing more people and bags into a car than we ever thought possible, however this was our first experience with a LENGTHY car ride down a road that would be for ATV’s and motorcross only in the states. When we finally reached the clinic, we were dropped off on the side of the road and tramped our way through a field of cows and goats to the clinic.

Kopanga dispensary is a small mission clinic founded by the United Methodist Church in Washington state, around 1yr ago. The staff consists of a few nurses and nurse aids as well as a lab tech and an administrator. We were given the grand tour by the head nurse, who treats children under 5, the whole place consists of a labor room, a counseling/adult patient room, a Maternal Child Health room, a lab room, an observation room with four beds and a pharmacy room (the labor room and observation room are pretty large probably 15ft x 10ft, the other rooms are about 5ft x 7ft). The clinic takes 50 Kenyan shillings (ksh) for children under 5, 100ksh for children 6-13 and 200ksh for everyone 14 and older. This covers their evaluation, any lab tests and any medications prescribed. After our tour we each split off with a nurse to see some patients for a few hours and then were invited across the grounds to the guest house where we had tea and some lunch, which was prepared by a wonderful mother daughter team.

After lunch we decided since we were so close to the border of Tanzania we couldn’t possibly leave without venturing across. So we piled back into the car and journeyed down another bumpy red dirt road winding through the country side, passing small collections of mud huts with grass roofs and small children running alongside the car yelling “Msungu! Msungu!” and waving furiously. ( I just realized this is the first time I’ve mentioned this phrase and I have to apologize for this huge oversight, as this is one of the first words we learned because it means “white person” and everywhere… I mean EVERYWHERE we go, we hear it) So after about 30 minutes of driving we arrive at the border town where Mr. Barasa greeted the border guard, who looked like just everyone else except he had on a nice polo with the Kenyan flag embroidered on the upper left chest. After a few minutes Barasa got back into the car and we continued on into what Barasa called “no mans land” apparently there is a small section of land that doesn’t really belong to either country?? So after a few minutes we crossed over a small creek which we were told is the actual border, before arriving at the border town in Tanzania! We all quickly riffled through our bags to pull out our cameras to capture the moment and the signs, for proof of our entry when Mr. Barasa’s eyes bugged and “no, no, no, no.. it’s not like Kenya, no pictures”! Stunned we all shoved the cameras back in our bags and Barasa got out to speak with the border guard to see if we could enter the country. As he came back to the car smiling he says “ yes, it’s alright we can come in and we don’t have to pay to get back out” despite our mild shock and confusion at the prospect of having escaped a fee we didn’t know even existed we rolled along through the town.
On the side of the road towards the end of town a sign for the police station came into view and a stern looking gentleman in a khaki uniform with a rifle slung over his shoulder, glared at our car as we tried to turn around. He watched the car intently as the driver executed a 20 point turn, when the car was positioned exactly horizontal in the middle of the driveway he began to slowly stroll towards us. Small pangs of panic began to surge through me, Mr. Barasa jumped out of the car and greeted the man, who continued to look stern and glare at the car full of msungu’s. After only a few words exchanged the two strode up to the car and I prepared for the third degree. The guard, still stern with every step, stopped directly in front of my window, grabbed the door and busted out a wide toothy grin and a deep booming baritone said “You are welcome!” So our stay in Tanzania was brief but pleasant.

MASAI MARA!!! – Early Friday morning we left for our safari on the Masai Mara. We were told we would be taking a short cut to save time and get to the mara early, so we were all for it. It was the bumpiest most ridiculous ride, 10x worse and longer than the trip to kopanga! Thankfully we were in a van, but I really felt like I was going to rupture my spleen it was so rough. The holes and ditches on these roads are more along the lines of ravines, I seriously thought the car was going to bottom out, tip over, or break an axle! Finally we reached the Mara and before we got into the gates we saw water buffalo and zebras! Not even a mile past the gate and we saw elephants and were only a few feet from a herd of giraffe! It was amazing being so close to such magnificent animals in the wild. As our day came to a close we watched the sunset next to a pride of lionesses lazily napping next to a stand of trees.
Our accommodations in the tented camp were beyond expectation and just to put it in perspective, it was the BEST shower we’ve had since we arrived in Kenya! The food was delicious and a giant beer was only 200ksh. We were up early and out to watch the sunrise over the Mara, water buffalo, zebra, ostrich, topi, impala and tomi gazelle were all out grazing in the crisp morning air. We saw a lioness and four cubs cruise across the plains into some brush. Later in the morning we went back to the tent, packed up our things, took one last phenomenal shower and made our way down to the Masai village. The Masai are native people who still live in the traditional style on the Mara, houses made out of cow dung and all. The chief's son Peter was our guide and explained some of their cultural practices with us. Later the men and women danced and sang and we bought a few souvenirs from them. Tammy traded a headlamp for a necklace and Le traded her watch for a carved club. On our way out of the park we luckily happen across a cheetah resting beneath an acacia tree. She was beautiful and smaller than I had expected. This trip was definitely a high point of the rotation, don’t get me wrong I love the medicine but this was spectacular!!!

PS. - I just waited 30 minutes for 4 pictures to upload and when it reached 100% it failed, so no pictures tonight, sorry

Pictures

I couldn't upload pic's this time but I was able to load them on the other blog I'm doing here it is http://kenyamay2011trip.blogspot.com/

Kenya week 2:

Unfortunately our preceptor was unable to join us due to a family emergency, but lucky for us a member of the group Safe Passage to Motherhood (who were here 2 weeks before us working in Bware helping educate women about pregnancy, labor and delivery in an effort to decrease maternal/infant mortality) Lelinda (or Le ) volunteered to stay on with our group for another 2 weeks. Le is a clinical psychologist and her experience with the community as well as her specialty has been invaluable to us in the last week. We are all extremely grateful for her willingness to stay and help us process our experiences here in country.

Migori – The town itself is probably a medium sized town for Africa as it has a level 4 hospital (St. Joseph’s) and the main street has 2 supermarkets, 3 hardware stores and countless other shops. There are open market type of stands all over the side of the road and down side streets. It’s relatively safe to walk around the main street in town during the day, just be sure to keep your passport wallet on a string tucked safely inside your shirt and not wearing anything that looks valuable is a good idea. We always walk together in at least a pair but the larger the group the better. Last night some of the students from Medics to Africa program (they are staying in the hospital guest house further up the road) went out to a disco (night club) but we decided to stay in. Most of the time when you’re walking through town people are friendly and everyone greets you with “habari” (hello, how are things) to which you respond “mzuri or salama” (good, perfect) and they are big fans of the handshake! You shake hands with everyone, everytime you see them and the better you know them the longer the handshake is.

St. Joseph’s Mission Hospital – In a word… AMAZING… there are so many things about this place that are both inspiring and tragic. The people here are so welcoming and friendly; full of such love and kindness at times it overwhelms my heart to see how selflessly everyone here at the hospital gives to the point of exhaustion. The resources have made me cringe so many times I’m almost in a constant state of shock. At the same time they do their very best with the limited equipment and supplies they do have. The most significant thing about the hospital that stands out for me is how much death there is, for a hospital this size the number of patients that die every day is astounding. Most of the problem is that people wait so long before coming in, because of money or transportation, by the time they actually come in it’s nearly impossible to save them.

Bware – A quiet farming community just outside of Migori. We visited Bware primary school and the kids were absolutely adorable and so excited for the books, pencils, crayons, paper, erasers and other supplies we brought. By far the biggest hit was the football (soccer ball) we brought, they went crazy for that. Then we met with the Buchwa and BBEKAS ( Buchwa is the community health aids group that is made up of mostly women from the Bware community and BBEKAS, an acronym for all the primary schools in the area, is the headmasters from each school) had a meeting during which they gave us some information about the issues the community and the schools are facing and the things we could address while we are here.

After lunch we were taken to meet our host family, all three of us are staying with Alex and Lucy and their 2 daughters Angela (who is making me a skirt) and their 5 grandchildren Whitney, Willis, Vincent, Sharon and Wayne. We left our bags there and walked up the street with Le to visit the family she has been homestaying with. Marselline Koskei and her husband own 10 acres, their daughter Annett took us on a tour of their farm where they grow; bananas, mango, papaya, avocado, pineapple (Heather got to pick a fresh pineapple which we will enjoy tomorrow) soya (soy beans), ground nuts (peanuts), kale, maze (corn), napear grass (for the cows to eat), and cassava. After that we walked back down to Alex and Lucy’s where we enjoyed dinner and some entertainment provided by the children and then us as we tried to remember the Kiswahili words to the head, shoulders, knees and toes song. Then the two girls braided my hair, before we turned in for the night. The next day Le met us in the morning and we walked up the street to a neighbor’s house where a group of monkeys live in the nearby trees. Unfortunately we were too late in the day for monkey spotting, but the view from the top of the hill was breathtaking. When we got back to the house the children were all waiting to play with us Tammy played some football with the kids, the girls showed me how to weave grass and then Heather and I turned a jump rope for the girls and learned some Kenyan jumprope games. All in all it was a VERY good week.

This upcoming week we will be going on Safari Friday and Saturday so next time I should have some pics of the animals.

Karibu Kenya! Welcome to Kenya!

We arrived safe and sound on Monday 5/16/11 at around 6am, the Nairobi airport was easy to navigate as most all the signs are in English and Kiswahili. There was a station of visa applications and declaration forms in front of the visa/passport desk where we all double and triple checked our story and paperwork to make sure everyone was on the same page. We breezed through both visa and customs and took our first steps outside into the warm humid air. We were immediately met by our host and guide Mr. Barasa holding a “Ray of Hope” sign at the exit. He was warm and friendly and I couldn't have imagined a more generous and wonderful man to help us make the adjustment to life here in Kenya. We were then packed up into a matatu ( small van, like a VW bus) where Mr. Brarasa prayed over the next leg of our journey. The traffic here is unlike anything I have previously experienced it seems as if there are no laws what so ever, no right of way, few signals, and lot’s and lot’s of traffic! Vehicles weave in and out of lines up onto dirt paths where pedestrians are walking, motorcycles with three people riding, dart between cars and busses, it really feels like a free-for-all everywhere you go. After only 1 hour in traffic we passed through the first set of security gates where a row of white Mercedes benz and Toyota camery taxi cabs waited for fairs. Around the corner the tall green gates of the Musmark guest house where opened when the matatu driver honked signally the security/gate man of our arrival.

The lush greenery of the Musmark lines the driveway in and the charming old English style cottage greets you with a tall ivy covered chimney. The staff is amazing Judy our main hostess is very friendly and ready to help in anyway. The main house is used for meals which are freshly prepared and are always delicious, comprised of a mix of traditional African dishes like Ugali and more common familiar things like grilled chicken or fried Tillapia. Our room was located around the back of the main house past the enormous bright green lawn, large gazeebo and rich landscaped gardens. The room itself had three twin beds with mosquito nets over each, two medium size closets and a small bathroom with tub, shower, sink and W.C. toilet (which flushes, as opposed to the latreen which we ran into later).

Our first week in Nairobi was primarily for orientation, we had a few lectures in the meeting room at the Musmark and a few field trips during those days, though Monday was mostly spent sleeping.

Road safety (which will coincidentally be a major factor affecting our trip in a few days time) was our first lecture, given by Bright, a wonderful woman who works for SOMETHING an organization dedicated to improving traffic safety in developing countries. This is an important lecture, as the roads here are quite dangerous at times and you really need to be alert and always aware of your surrounding while walking ( and you will do A-LOT of walking). Kenya doesn’t really have a good emergency response system. Ambulances are few and far between on top of that they are just a taxi matatu with a stretcher, they are not staffed with trained personnel so there is no care provided to the patient enroute to the hospital. Most of the time it is good Samaritan’s who extricate the injured and the majority of the population have no concept of basic emergency care and sometimes actually do harm in an effort to help.

Masai Market – We experienced the main market on a Tuesday (there is another one on Saturdays, which is, I’ve been told, a little smaller and not as hectic) While the market itself is filled with a generous array of wonderful items that make great souvieniers; carved and painted bowls, antique and new masks, jewelry, scarves, t-shirts, carved statues, batiks, leather items, ect.. You will be OVERWHELMED not just in the variety of items but the attention you receive, be prepared to be swarmed by 5-6 men (think of the most aggressive, personable used car salesman you have ever experienced and multiply him by 5) and then barter like a miser. It is easy to get split up because you get surrounded, do not panic you are safe just keep an eye on where other people are ( it will be easy to tell, just look for the other giant group) These guys are middle men, brokering deals between you and the vendors, they will mark up the goods by thousands of shillings/hundreds of dollars. Barasa told us to counter offer 1/3 what they are asking and not to pay more than 1/2, my experience suggests that will work best with the vendors themselves, the middle men start too high for this, so I recommend having a ball park for what you think is reasonable in US dollars and start with ½ of that number. I also HIGHLY recommend really understanding the conversion and have a few numbers converted out so you can quickly ballpark it. (ie: when we were here it was 85:1 so roughly 500ks = 6$ 1,000ks = 12$ 5,000ks = 60$ 15,000 = 175$) unfortunately I didn’t have these estimates memorized until after the market. Also something I wish I had known is that if you really like something but the middle man price is to high and you walk away, when the middle men leave the vendors will find you and barter at a more reasonable price.

Kawangware – This slum is close to the Musmark and you’ll spend a day there touring the clinic, the learning center and visiting some of the homes of the children. It is an amazing experience, you will be moved to the point of tears many times that day and I can’t begin to describe all the things you will see and the impact it will have on you, so I won’t try. I will however give you some tips

– you can take pictures at the school, the kids and mama’s are honored to have their pictures taken when they first come down and sing for you. After that always ask first.

- You should put your camera away while walking through the slum and no pictures on the streets, you can take pictures of the kids parents and houses, but again ask first.

- it costs 500$/yr to sponsor a child through primary school - 800$/yr for secondary with an 8yr commitment for secondary.

- There will be a child that completely steals your heart, Cynthia stole mine.

Kiswahili lessons – Well worth the effort, Mariam is an excellent teacher she makes it fun to learn and is very patient with those of us who struggle. Kiswahili is pretty easy to learn and very easy to pick up at least a few phrases that will not only come in handy but win you lot’s of friends for you effort. Everything is pronounced just as it is written only vowel letters are read differently ( A = ah as in Kenya E= a vowel sound a I = vowel sound e, O is o, U = oo as in school ) so Asante for reading.

The trip to Migori – Our adventure began at 8am we all piled into a matatu and off we went. About 1.5hrs into the trip a car was trying to overtake (pass) another car and went off the road and down a steep embankment about 50-75ft. We stopped and everyone hopped out Tammy and Barasa ran down the hill while a few of us unpacked a first aid kit and a blanket for a stretcher. The patient was carried up the hill in a sheet and put into the back of a SUV driven by a British man who was familiar with the area and knew of a hospital that was close. Tammy and Barasa hoped into the SUV and provided care to the patient while the rest of our group followed in the matatu. Unfortunately the driver of our matatu lost sight of the SUV and did not know where the hospital was, to make matters worse he didn’t speak English and was lost. Eventually we made it to the hospital where we met up with Tammy and Barasa, by this time it was too late to continue on so we returned to the Musmark for the night.

The trip to Migori: Take 2 – Went off without a hitch. The trip is around 7 hour’s long, try to stay awake at least the first two hours because it will take you near the Masai Mara where we caught a glimpse of some zebra and giaraffe. The countryside on the way is beautiful, dotted with small communities every few kilometers. I recommend watching out the window and appreciating the beauty, instead of watching how the vehicle is driven, all the close calls, the anxiety and panic attacks.

Today was our first day at St. Joseph Mission Hospital, it was an amazing day! We were warmly welcomed by everyone at the hospital. After a brief meeting with administration and introductions to the clinical officers (Africa's version of PA's) Dr. Agullo took us right under his wing. We examined a few patients and walked over to the theatre (OR) and helped deliver a baby!! how's that for as Dr. Agullo called it "introduction by fire". After a tour of the entire hospital from the lab and pharmacy to the morgue and laundry we met virtually every staff member and were genuinely welcomed by each one. We then headed back up to sort all the items we packed and donated to the hospital. It's amazing how much we packed into those 50lb bags and it's apparent how grateful they are for each one.

It's been a long day so I am about to sit down to a wonderful meal prepared by our amazing house hostess Alice.

until next time, Utapona (be well )

The Day Shift.....

So after two weeks I think I have the day shift pretty much down, which definitely does not mean I am good at it. Day shift is VERY different than what I thought it would be, it's like more of hospitalist/internist medicine. As in you deal with a lot of internal medicine problems on all the trauma patients that have been admitted and are either recovering from or waiting to go to surgery. So my days look something like this...

6am - 6:15/30ish - sign out in the west wing ICU- night team gives you the run down on any problems your patients may have had over night and the scoop on any new admits on your assigned "wall" of the TRACU or upstairs (peds, ob and med surg)

6:15/30ish - 9am - sit in TRACU on a computer looking up all the morning labs, diagnostic imaging, reviewing other services consults or progress notes, seeing your patients (ie: physical exam) and writing notes on your patients. ( now this may seem like a long time, especially for me because I am only allowed to see at a max 5 patients, but trust me when the patient has a few chronic conditions on top of fractures, mental status changes, alcohol withdrawl symptoms, and electrolyte imbalances.. the time goes by waaay quicker than you think.) What is amazing to me is that in 2.5hrs these PA's can get most of their notes done on an average of 10 patients! They are AMAZING!!

9am - 12 (or sometimes 1,2 or even 3) Grand Rounds - yep, the big bad scary ground rounds of legend. Which actually turn out to not be so bad for the most part. But just like anything else it depends on the attending your rounding with. Some are slower than others, some teach as they go, some sit down with you after rounds and go over your notes with you. Presenting during rounds is still pretty rough for me, though after you've rounded with the attending once and know how they want you to present it's much easier and a little less intimidating. If I had one piece of advice it would be to WRITE down your lab values and do not be afraid of saying I DON'T KNOW. I don't know is always better than trying to bluff your way through something! I've watched it go very badly for people who try to do this and it is ALWAYS better to honestly answer any question, you will never ever be able to predict everything the attending will ask you so I try and write down as much of what I think is pertinent.

LUNCH - the PA's will usually make you go eat lunch even if rounds run over and clinic is waiting for you, on Friday's (even though that's usually your day off) there is a lecture from a couple residents that is interesting to attend if your there.

After rounds the rest of your scheudle depends on what day it is

T,W,Th - 1-5pm = Trauma clinic - it's fast paced, hectic and takes a while to get used to. ( I wasn't a fan) but one of the cool parts about doing nights first is that sometimes you get to see some of the patients you took care of when they were first admited.

S,Sn,M,F - finish up all the order changes to the patients you saw in the morning, write discharge summaries for patients that will be going home that evening or the next day. Depending on which PA your working with the rest of the day is spent learning either from quizing or lecture or it's your time and you can study, enter typhon, watch TV, take a nap, or blog :)

the night shift...

The Trauma night shift has been quite the roller coaster ride for me. Extremely mixed emotions, some very low, lows and happy highs.

The highs:

Lot's of learning: managing ventilator patients, Hyponatremia protocols, calculating a FeNa, indications for exploratory laparotomies, ECMO, Normal pressure hydrocephalus, CIWA protocols, evaluating a trauma, and the list goes on and on...

Procedures to do: Inserting a foley catheter into a ruptured bladder with vaginal fistula, Retrograde urethragram, Femoral stick ABG, lots of sutures and stapling. helping with chest tubes, Arterial line and exploratory laparotomy.

Seeing really cool injuries - Giant scalp laceration I could stick my entire hand down, stab wound to the neck, unfortunate C-spine fractures with spinal cord involvement ( jury's out on future paralysis) fractured pelvis, subdural and subarachnoid hematoma's, X-ray of roofing nails from a nail gun to the chest and heart!!! (I didn't actually see this patient but the x-ray was pretty impressive by itself)

Super awesome preceptors, who are smart and fun and happy to teach.

the Low's:

Mostly consist of my own inner dialog berating myself for not knowing the answers to questions, (especially the one's I actually DO know but somehow fail me when under pressure).

and the worst

The Attending who's displeasure with me was palpable. First he ignores me, then asks my preceptor why I'm doing the ROS cause I "apparently don't know what's important". Then he tries to make me look like a fool because when I asked the patient "any surgeries" and they said "no" I foolishly reported a negative hx of surgeries, so he calls me out on it cause he knows the patient had some kind of abd surgery cause of a scar (which he found doing the PE, which only the Residents and Attending's do on a level I trauma) Yep that night was an all time low and I cried on the way home from the hospital in the morning. (luckily he's now on days and I have new Attendings who are AWESOME!!)

Overall trauma is shaping up to be every bit of the amazing rotation I thought it would be. I would love to work in trauma... someday but I think I'll need a few years under my belt before I feel confident enough to be there (I'm guessing less "impostor syndrome" anxiety for me).

TRAUMA!!!

Tomorrow I begin one of the most anticipated rotations scheduled! I am so excited I can barely contain myself!! As I understand it I'll show up at 6am get my scrubs, a tour and introduction to my new home for the next 6 weeks. I will then be sent home to sleep, so I can be ready for my 12 hour shift starting at 6pm ending at 6am. Yep that's right - Night shift straight out the gate! I'll be working at least 72hrs a week with Fridays off. I'm not sure how often I'll be blogging during this rotation as I'm told it's exhausting. So just keep your fingers crossed that gun shot wounds, stabbings, random accidents and MVA's have a slight increase over the next 6weeks.... but you people stay safe!

Back in the saddle...

so technically it's a chair not a saddle but here I am again, sitting in a classroom listening to lectures. This week is a recap back at school, when we here a few lectures, network with people from class, learn about contract negotiation and writing a CV, discuss plans for our graduation party, awards, and take a boards practice test. Some good stuff to review yet.... I'm sooooo done with sitting in a classroom!!! After being out there and doing, it's tough to come back and sit passively receiving information. At least I get to see my favorite people again, that's the biggest plus of PPS (Professional Practice Seminar) week.

Ok class is starting now, so back to the learn'n

Breast-Specific Gamma Imaging vs. Mammography

I cannot upload my poster because the formating is not recognized. So I'll just tell you that BSGI is more sensitive and specific (ie: better at finding breast cancer) than mammography, especially in women with dense breast tissue. It is similar in cost to mammography and thousands less than MRI. oh and lastly it doesn't require crushing breasts into pancakes.... yeay! here are some images off the web so you can see the difference in images produced.

Almost complete

Capstone paper is nearly done, the bulk of the work is finished. After meeting with the writing consultant all that's left is just the finishing touches. Last is the poster, which I plan on being done with tomorrow. I am also thinking about actually submitting my paper to a journal for publication after a few professors comments. But honestly I really don't feel like what I produced is truly journal material. The biggest issue is I think a lot more work to spruce it up to make it journal worthy would be required and that's a big "NOT gonna happen" from me. But at least I chose a topic I didn't end up loathing and I learned a ton doing it. ( I'll post the poster when I'm done if anyone wants to get a synopsis of what my paper was on)

Tonight I did a shift at Essential Health clinic, the free clinic our university works with. Two professors and two first year students were there with me. It was a little rough to get back into the swing of writing SOAP notes and presenting after having a 6 week break from it. But in no time at all I was back on my game. High/Low lights of the night included an interesting case with a pregnant woman (they always present more of a challenge) and a Digital Rectal Exam (I've done probably 10 of these and I think I'm kinda done with the butt, really I don't ever want to do another one ever again).

So now I have around 2 weeks of blissful vacation before I start trauma! I plan on studying my ACLS and Trauma algorithms and cleaning up the house. But the evenings belong to Ryan and I, so nice to have so much down time to spend with him these last few weeks. It's like I got my life back. And ooohh how I missed my life with him!!!

Oh other important milestones.... I just got my ticket to KENYA!!! That's right 59 days and counting until I'm on a jet plane to Africa!!!

Paper of ..... procrastination!

ugh I HATE this paper! I find myself procrastinating at every opportunity. The topic is interesting and I enjoy reading the articles but writing this is torture! I just want to get through it so I can have a few weeks of leisure time, but I can't seem to make myself sit down and power through it!

Bad News.....

it's tough to give to patients, this is one of the most difficult things I've had to do here in prison. I've been out in the world treating patients (true it's only as a student, but still..) for almost 10 months and this is the first time I've had to give people bad news. Not, "yep you have a broken bone" or "looks like you have pneumonia" ... or even "you're a diabetic now". Nope I'm talking about telling people chances are they will soon die. It's a lot harder than I thought... and I didn't think it was gonna be easy in the first place.

The first time was the worst, giant tumor in the middle of their chest, Anaplastic Thyroid cancer, the invasive kind = Not good. I gave myself the pep talk and tried to remember... "go slow, don't use medical jargon, don't forget to talk about DNR (do not resuscitate) and for God's sake don't say anything stupid! It was so hard to do, I remembered once you say the word CANCER you just have to stop and let that sink in, cause anything you say after that falls on deaf ears. You have to give them time to process what that means and it's really hard to watch. I could see it in their eyes... they went all glassy and distant, the brow furrowed and they looked away, seconds felt like hours and it's all I could do to make myself keep quiet. I wanted to ramble about "what type of cancer it was on the pathology report, the most common treatment, the 5yr survival rate based on age and health factors and blah, blah, blah, shit that wasn't going to mean beans to the patient.... but oooohhh how I wanted to fill up that horrible silence!! When the patient finally came back from thought and began asking questions I fell into the medical jargon trap.... I rattled off a bunch of statistics and half way through realized I need to stop and make sure the patient understood. I managed to only put my foot in my mouth once, and unfortunately that was one of the things that stuck with the patient cause they repeated it back to me.... twice Uuuuggghhh! why oh why did I say "worst" even though it was true ( it's really rare and less than 5% of patients have a 5yr survival rate) I still shouldn't have said that. But I got through it and I'm sure it wasn't the best but it couldn't have been the worst "you have cancer" talk ever.

I guess I was just kinda surprised by how affected I felt coming away from that talk. I really didn't know the patient it was only the second time I'd ever met them and after it's not like I'm the one who has cancer.... It was a weird feeling.... I guess the closest I can come to describing it was a feeling of guilt... like I was somehow responsible for giving them cancer and there's nothing I can do to make it better. Usually when I give not-so-good news to people I always get to say "now here's what we're gonna do to get you better". But not being able to say that just leaves me with this unfinished feeling, like a job you left incomplete. Then as if to add insult to injury it's a virtually necessity to let it go and move on to the next patient! I'm telling you it was a really difficult day to get through. Afterward my fantastic preceptor Robert told me " you can't carry it with you... you gotta let it go or it'll drown you. It's good that you feel it, just don't take it home with you."

The last patient I had the talk with has the wicked combo of TB and AIDS, unfortunately this combination of diseases is pretty awful. The dangerously low CD4 count (T-cells) means they're susceptible to opportunistic infections and because her immune system is low it's like a free pass for TB to start acting up and rampage through her body. I was much better this time around and I thought the patient took it amazingly well... until I left the room. As I started to walk away I heard them break down and begin to sob, and that guilty feeling came gurgling up from my gut.

I know I said it was great to see all the super sick patients, with their complex diseases and super rare conditions... but I don't know how I'll ever get used to giving the truly bad news. but unfortunately I'm pretty sure someday I will.

The Big Easy..

New Orleans... jazz and jambalaya, hurricane drinks and voodoo... I wish I had had more time with this amazing city. Guess I will just have to go back, the sooner the better :)

Life in PRISON...

Well not so much for me but those are the people who's care I am now responsible for. So here I am on my Internal Medicine rotation at the Carole Young Medical Facility (CYMF). So I figure I should start off with a little about the prison itself. CYMF is a minimum security prison facility for inmates with chronic diseases, terminal conditions or post-op wound healing. It also houses 300 female inmates most of whom work in the hospital doing house keeping, janitorial and kitchen work. There are 5 "pods" or wings of the hospital with roughly 50 - 100 inmate/patients per pod. I was surprised to learn that most of the patients are men, there is only 1 pod for females and most of them are post op for some kind of surgery or are cancer patients in between rounds of chemo/xrt (radiation treatment). I was a little apprehensive knowing that most of the patients I'd be treating were going to be male, until I saw the patients. Most of the male inmates are seriously sick, 70+ and look emaciated, amputee's or can barely walk... needless to say they aren't very intimidating. However that doesn't mean I'm not uneasy or stay vigilant while in the room with them. When I see patient's I always have a guard with me and the door is always open. I have never felt unsafe, threatened or really had any trouble with a patient at all. According to our Preceptor staying at this facility is highly coveted, apparently its one of the nicer facilities and so inmates don't act up for fear of being transfered. So now you know a little about the place, here's a little about what I'm doing.

This place is FANTASTIC! I'm getting to see all kinds of crazy stuff!! These people are really, seriously ill and dying. A little morbid and kinda sadistic I know, but you have to look at it from where I'm at... I've never seen any one with Hep C in liver failure with a gigantic belly that needs to be tapped, and then I get to help do the paracentesis! I have seen Myasthenia Gravis a disease so rare only 10 in 1 million people have. I have a patient with Schizophrenia (and you all know how much I love the crazies!!) a patient with TB and AIDS another with Hodgkins lymphoma. It's amazing to see so much pathology, every patient I get has some kind of seriously horrible disease. Most family med practitioners, in their entire career might see, if their lucky/unlucky enough, one or two of the patients I've seen just in the two weeks I've been here. I'm learning soooo much, how to treat really sick people, rare diseases, how to admit, discharge and some of the outrageous ways our tax dollars are spent on inmates. Like the illegal alien who is basically a vegetable. When prisoners are brain dead, terminal and close to death they are paroled to hospice and the family takes over care and fee's for their end of life stage. However since the patient is an illegal he is not eligible for parole and the state will have to pay for his comatosed ass until he dies. Moving on.. There's also lots and LOT'S of wicked, nasty wounds to clean and dress. Now I'm a freak for the gross stuff, but there are a couple wounds here that made MY stomach churn, mostly it was the indescribable foul stench that got me. However I still loved it ;)

Well we have a long weekend coming up and I'm not sure what I'll be doing ( Austin? New Orleans? Oklahoma?) but I'll be sure to post when I get back.

Break, Road Trip and New Years.

Break...

It was soooo nice and yet over so soon, my 2 week winter break was all too short. Unfortunately before break had barely begun I got some sad news regarding a family member and spent a few days visiting in the hospital. But my family is a tough bunch and we don't go out without a fight, so decisions were made and the fight has kicked into high gear! I love my family and I'm very glad they are such good and wonderful people it makes it soo easy to love them more and more every day. I did manage to cram time with lot's of friends and family into Christmas festivities but the whole week just left me feeling like I needed more time just to take a break from break! I think it felt even shorter because 1/2 way into it I left for my next rotation. Yes my boyfriend Ryan (aka Billy ) helped me load up my nimble little versa for a 3 day road trip to Texas. Ry has a friend from his Army days who lives in San Antonio so we decided it would be fun to come down early and visit.

The Road Trip was loooong we drove from 3pm to 9am non-stop before getting some breakfast at Denny's and taking a 2 hour cat nap in the parking lot. The pass between La Grande OR and Where ever ID with snow and ice and big semi truck was not fun! I was so happy Ry was with me and even happier when he took over driving in that crap! After we crossed over into Utah it got pretty boring until we drove into Salt Lake City but at 3am we couldn't see any of the landscape or the city itself, what we did see was several cops riding our bumper. I'm assuming it was because they could sense we weren't Mormon ;) We drove past Archs National Park, but by then I was so delirious that when Ry woke me from a half sleep I couldn't get the words out to ask him to stop so we could go see the famous giant rock arch. Later after our nap, when I was more coherent I got to drag him to Four Corners ( AZ, NM, CO and UT). Not much to see there but worth the 6$ for me and Ry to take a few pics get a snack and use the porta-john. Roswell NM on the other hand was not worth it. I can't tell you how jazzed I was to roll into a dusty small SW town filled with Alien themed everything.... which is what I had imagined. What we found was Walmart, Applebee's, 4 Sonic's and less than a block of Alien nick/nack shops..... what a disappointment. The most amazing thing about the drive through Texas..... I only got pulled over once, and I even though I was going around 90 in a 65 (at night) I only got a warning :)

San Antonio was great! Ryan's friends David and Anita are amazing, Anita was off work the entire time we were there and insisted on cooking for us, which was really sweet of her and delicious. They took us to a Brazilian restaurant of meat on New Years Eve (sooo delicious I'm kinda drooling just thinking about it) and then went back to their house to play games and light off fireworks at midnight. Oh yeah and I don't think anythings illegal in Texas (haha) the boys got big mortar fireworks like in professional displays, it was like being in downtown Portland, only this was just random suburb neighborhood. It was one of the best New Years Eves I had, good friends, good food lot's of fun and spectacular firework show.