Reflection on Rotation

My long term care ( LTC) rotation was very educational and I was exposed to a whole other world of medicine that I had not previously had experience in. The hardest aspect for me in assessing patients in LTC was assessing patients who had severe dementia, aphasia, or who were non-verbal. The assessment had to mainly be on signs documented either from nursing or from what I assessed, as well as labs, and other objective data. This is a learned skill knowing what signs to look for with common conditions in this population and what diagnostic criteria you need to treat. I did see quite a few treatments of conditions such as osteomyelitis without an x-ray or culture done but treated prophylactically with non-healing unstageable wounds with elevated CRP/ESR. This was done in patients who deemed unstable and  the decision was to treat in-house for possible diagnosis instead of sending out for radiology consultations or hospital. There is a lot of treatments done to reduce hospitalizations and try to treat conditions in-house to avoid sending patients out. This was uncomfortable for me as there is not a CT machine, quick lab turn around or acute monitoring however this setting is different than any other. Many patients have DNR/DNI and even DNH status. However, the line between treating a condition in-house with someone who doesn’t have an DNH status was very interesting for me to see.

I have many memorable experiences, but I will discuss one in detail. I sent to evaluate a 94yo F with chest pain all by myself as the other providers were in a meeting. I went upstairs saw the patient was in distress and clutching her chest and asked for a stat EKG, took her vitals and grabbed her chart to see the MOLST status and other comorbidities. She had a previous MI several years before, s/p CABG years earlier and had a pacemaker placed. Her BP was >200/>90, HR was stable from the pacemaker and pulse ox was 97%. She was complaining of SOB and feeling like she can’t breathe the most, so I asked for a nasal cannula, connected it to the wall and turned it to 2L/min. The patient appeared very anxious and stated her chest pain feels crushing and told me about nausea, vomiting and diarrhea she has  had for the past 12 hours. Her EKG was difficult for me to interpret as she had several old MI with ST elevations and Q waves and a LBBB. She did not have a previous EKG so I was unable to say that this was a new or old finding. I texted all of this to the medical director who sent me there, so she came down to evaluate. She asked me what I wanted to do, and I said give nitroglycerin, famotidine and send her to the hospital for ASC work-up.  However, when I talked to the patient, she did not want to go to the hospital even though she was not DNH. Therefore, we gave her nitroglycerin and famotidine and did not send to hospital. We did not give BP meds initially as nitroglycerin and famotidine may alleviate the pain and reduce the BP however the BP continued to be elevated so we gave her another dose of amlodipine that she takes daily for BP. She also takes 81mg aspirin daily. When I left the LTC, I felt uncomfortable that she was not being sent to hospital but again this was a new setting for me, I talked it over with the medical director and she said, this patient already had a CABG and pacemaker, she is not going to be sent to PCI. She stated that she is likely to be managed with the same medications we are giving her here plus she also does not want to go. The next day, when I came in, the overnight doctor had sent the patient to the hospital due to increased pain in the epigastric region, he suspected R-sided MI due to the gastrointestinal involvement. The patient pains was not able to managed and she requested to be send out so she was sent out. I followed up with her course at the hospital and she was diagnosed with acute mesenteric ischemia and underwent a partial small bowel resection. This confused me as I had seen the situation only through ACS eyes and did not focus on the gastrointestinal symptoms plus the patient did not have a “pain out of proportion to exam” she only had mild epigastric pain when I evaluated her and complained more of chest pain and SOB.. This was a great lesson for me to not focus too much on one diagnosis and to keep other differentials in the forefront as well. I also learned a lot about the ambiguity of DNR/DNI but not DNH and healthcare proxy requests. There is a lot of multidisciplinary meetings, education and ethical situations encountered in the long-term care setting. This was a great experience for me to understand the medical cases and ethical nuances of this setting.

Site visit summary

Both of my site visits with Dr. Davison were much longer than any other site evaluations. Her attention to detail, motivation to find teaching moments and drive to improve us professionally and scholarly is appreciated more than I can write in one summary. It was discussed how electronic charting has in some ways replaced the need to learn formal H&P presentations. However, during rounds such as grand rounds it’s important to know the proper organization of H&P presentations as there is a standard structure in which patients are presenting and doing it correct adds credibility to your presentation. My structure still needs work and that is something I focused on with Dr. Davidson as I can present very scattered as I want to just talk about the pertinent positive, vital signs and assessment/plan like an ED/urgent care/surgery presentation however things stated in my assessment would be missing from my HPI. I was also taught the correct way to present an article and discuss the findings in a scholarly way. Dr. Davidson picked up on the fact that I wasn’t comfortable with what anticoagulants should be used when and gave me the assignment to research and present that at the next meeting. I now feel very comfortable with anticoagulants. We also discussed how we may have been taught how to evaluate MSK in a normal patient and document normal findings however I am lacking in how to document or assess abnormal findings such as degrees of flexion in joints ex. with contractures. This is something I will need to watch videos and have this as a goal for me to focus on during my orthopedic clinic surgery rotation week. It takes a lot of effort to do site visit evaluations the way Dr. Davidson does and I thanked her many times for caring enough to give the important constructive criticism and assignments that have brought me closer to becoming a well-rounded physician assistant.

Summary of article

I chose this article due to the palliative care consults I attended and the staff’s views on immigrants’ perspective of palliative care. Several of the providers I was with told me that immigrants had a harder time choosing palliative care for their family than those born in the US. Their explanation of this viewpoint was, in their home country they may not have had the opportunity or access to the medical advances to prolong life that we have in the US. Now given the opportunity to prolong their loved ones life, they cannot reason passing it up.  In the United States, many people have access to medically advanced procedures and with government-funded insurance, individuals cannot be denied live saving procedures due to finances. However, in my observation, the health care proxies and families who did not want to initiate palliative care or hospice care varied widely in their nationality and birthplace background. I personally, saw many individuals who still thought that hospitalizing someone was the right choose regardless of condition. Therefore, I was interesting to see if any statistics were available on this. The article I found was about a 2018 Health Information National Trends Survey done to assess the level of knowledge on palliative care in the public and who people went to find out information about palliative care. Over 3300 individuals participated in the survey, individuals born in the USA and those immigrated to the US. The title of the article misled me to think that this was an equal depiction of the difference in viewpoints of palliative care of those bornin the USA and those immigrated to the USA. However, when looking at the data, 85.3% of the participants in this survey were born in the USA and only 14.7% of the participants were not born in the USA. Therefore, the article findings of” about 70% of those born in the US and 77% of immigrants responded that they had “never heard of palliative care” was not an equal result. The results did say the immigrant response was (weighted) but think the sample size of 492 is too small to compare to a “Born in the US” sample size of 2846. The articles conclusion states that “perceived knowledge of palliative care is poor generally, regardless of birthplace.” However, more studies need to be done with a more equal amount of participation of immigrants. I would also love to see a survey with different generation of immigrants and comparison of immigrants from different countries as well.