OMG it has been so long...I am not sure what has happened to me and my ability (or inability?) to write. The last post was 2017 and everything about that post remains true. So true.  a few things have changed, as I am in Fort Collins- which is great- but as of yesterday Nick has had his daughter born, and this feels...big. Her name is Rosemary Deloris Arcos-Strayer which is a mouthful but she is TRULY adorable. So being closer to them might be nice if I can make enough money to live here- A2 is VERY expensive! But I really enjoy the walkability of A2. So- there ya go. 

Things that changed- Divorce from G happened and WTH did I ever think that the spots would change> It was expensive- I lost SO much money from this relationship. But the end result is its over and have been single since 2016 essentially. The divorce took forever (my lawyer was an ass- and actually said to me "what did you ever think would happen??" which while its true, kinda mean. My lack of success is becoming legendary. And I'm 100% okay being alone. I HAVE dated a bit and none have been what I would call a success but I have learned from each one. I just don't know...

I moved back to FoCO and it has been lovely, I have a lovely, humble home which I enjoy greatly, I seriously went crazy on the gardens,  I built raised beds and did a terrible job this year doing veggies but this was my worse year- there was little incentive to make it work well this year, I did not water enough which just is not a good plan. I will do better

I also did get a horse- not ANY horse but the amazing Heldig, She is a wonderful mare, kind, cuddly and everything I would have ever wanted in a horse. She is tough and has a great work ethic, I am endlessly proud of her. But I am not sure that keeping her mine is feasible. It will remain to be seen. I am leasing her right now which is helpful. Still expensive though!!

New barn project

Okay, yeah- its been years, but here I go...and this time, it will chronicle the rebuilding of a life with horses.

I won't bore anyone with the details, but suffice to say that if I did not like transitions, well, I got my fill in the past 5 years. SO...

I find myself with same cats, one new dog, one LESS dog, and several less horses and a new husband. Change anyone?

My life. Actually, this is pretty damn close....

And I spent a few lovely years in Co- Fort Collins to be precise and it quickly became the best place I have ever lived. I made several amazing friends that I will hold dear to my heart and am so thankful to have met them. And I had a great boarding situation, with one of those friends on the Reason Bandwagon.  The cynical person that I am says i did not deserve to be in such a great place. So fates pushed me back to the Carolinas- first to the worst job I have ever had for SO many reasons...and in a town that honestly, except for a well placed Pelican Balls, was the worst place I had ever lived in a house that had too big of a yard to not have my horse at home again. Took as long to mow, with no real benefit of seeing the ponies out the window. Couple that with terrible boarding situations, and well- Mama wasn't happy. Not one bit.

Checking out Craigslist- I found a wee ad that proclaimed a farm house with "endless possibilities" that I drove past and fell in love with. I needed to really think about that endless...

And I quit my job- and as hard as that was financially, I ended up getting a great job- amazing job- in Hendersonville. Okay, far away from my sweet farm house with several issues, but still the best. Job. I. Could.ever.imagine.

The Reason...literally

And another REAL reason...

And we moved in. OMG- the dump trips, the water pipes breaking, the bugs, and oh- did I mention that the deck was an accident waiting to happen because the back of the house was falling? Like 4.5" falling? Oh, and a barn that is...32x30. Who DOES that?  When I figure out how to add pics I will. But for now- just imagine..... Okay- GotPics...

My family....sigh....

Looks QUITE nice, right? Its kinda like someone seeing me in the dark- MUCH better. I like myself better when my contacts are not in-kinda the same

And this-- this is why-really why. Horse make the landscape look better, don't they?

The dog and pony show

A bit of a move update. I am planning on making the most final of my major moves this coming weekend. I am very much not ready. The house is not sold, so I can still move things down slowly. but fear as I start my job, I may get overwhelmed and just want some sort of normal in my life down there. What that means to me right now is not entirely clear, but I am hoping for clarity soon enough.

The past four years have NOT been normal. I wonder how I will handle normal??  I am certainly looking forward to normal!

I took Nick to Chicago for his great Embarking On The Coast of California Bike Trip- he got a great airplane ticket from Chicago to LA.  

Millennium Park- dead center, that's us!

A happy accident photo. Gotta say I love my iPhone!

If I think too much about this, I realize I am a total idiot to let him do this. But I am not thinking too much about it, and instead realizing that there are few times in life where you can pick yourself and forget everything and just do something like this. This is his time. We spent a bit of time wandering in Chicago the day before which was great. I did manage to price line the worse hotel in the history of the universe so sleep that night was...not great.

I remember this fountain as a kid SO well, inventing stories in my head about the horses (actually serpents I think?) and loving the colors at night. Annie used to take us there, it was just down the street from the Apt that she and Dad had. 

I did not cry when I left him at 5 am, and he is currently on the beautiful coast of CA, in Santa Barbara. Lucky boy!













SO! The move!

First shift of animals will be Poppi, Cats (maybe all? Not sure if I can deal with all those cats in the car!), Tahoe, Bobbi, his Donkey and Wrainthur. Plants, hopefully. 

April, my dearest friend for over 21 years, has decided  (bless her) that she is going to drive down with me, taking 2 of my horses and the donkey for me. I will follow with my car (which is getting fixed as we speak) and b-rup which needs a new floor. I know I'd stress if I had any horses in there. The stuff in it is just fine. It's the thought of the horses getting hurt that would freak me out...especially after the Pollards trailer accident this past week- and since they lived in our house for a few years before we owned it, I figured that better safe than sorry.

Bottom line is this:  April knows me better than I think anyone does, and I truly love her for just being April and for loving and caring for me in spite of me.

I got a call this evening from a woman who heard from the Voice of Tryon  (Okay, not really, but This Week In Tryon really has all the happenings in the area and it's due to TWIT that I'll be able to keep up!) that I was looking for someone to help me keep track of feeding, etc when I was working. Ok- this may seems small but it's actually HUGE to me. One less thing to fret over.

More soon, but gotta pack!

What I will miss about Ann Arbor

Call it my top loves list...not sure what will and will not make it on here.  I admit that the Five Year Engagement movie did highlight a lot of what the outside sees about Ann Arbor, in particular the most amazing Zingermans, which goes without saying is the absolute best. Yes, a sandwich cost more than my first apt did, but oh boy, worth it! The Bakehouse is outstanding, and of course, Mr. Nick worked there. Enough said!

But....starting with (what I am pretty sure is my TOP-Pun intended) is Summer Fest!   Top of The Park is a reason to be in Ann Arbor in the summer.  The list of bands that play is amazing, from the Ragbirds to other local bands- many of which will go on and become national names. Truly outstanding.

 Click on the link and I DARE you to not want to get down there and get on your dancing shoes. The movies are great, and the atmosphere is always wonderful, festive and - well, brings tears to my eyes to leave A2 just as summer festival is starting.

Of course, I just found out they are playing in Evanston! Ragbirds in Evanston! A not to be missed show!

And then,The Arb...

this past year with Nick

Nick was very tolerant of my desire for pictures

There is a lot of A2 that is not seen by the causal visitor and the Arb has to be the best of the not-seens. It's beautiful there. I would often take family members of patients down there when the weather was nice when I worked on 7C. What I remembered most from living in the hospital with a sick family member was that leaving the hospital felt wrong but was essential-the old line of "you have to take care of yourself to take care of others". So I would bring whatever family member  I felt needed a walk down the steep stairs outside of Taubman, and within a 5 min walk, was along the river. Blissful, even in the midst of turmoil.

Maybe I need an Arb Walk....

Then, as far as food goes, Frita Batidos has to be a top pick for me. Just the general feeling of the place makes it a win on all levels. And the milkshake with the added rum? Oh Dear God...nothing better. I am not a foodie, but Fritas somehow has the perfect mix of...perfect. If you're in A2, it's a must.  Then, Pilars Tamales-   first had them a the famers market, and once I found the cafe on Liberty, tucked away in a strip mall, I found my place when I needed a great tea, or just some good old comfort food.   Marks Carts is great for a quick lunch, again, hidden somewhat from the bustle of the rest of the town, but once you find it, you are sure to go back.

Main Street won the award for being a top ten Main Street. It is. I think this is deserved award, and I will miss Main Street for a lot of reasons. The bustle on summer evenings, so many outside places to eat- festive even when its just a normal night. So many places that are Go To's for me on Main Street- Falling Water as well as  Peaceable Kingdom are both places that I can actually enjoy shopping at. I am not a big shopper, but those 2 places often get the nod when I need the perfect gift.

And since you're so close. stop by for Sonic Lunch  another great perk of Ann Arbor in the summer. It's usually packed, so go early and stake out your space. Bank of Ann Arbor really does great things for the community, which is just so nice!

The Farmers Market has just started to expand to an artisan market during the fall and winter months. Usually there are several crafters there during the normal farmers market, but what I love the absolute most is the plants, usually native to the area. If you see my "what I miss about my farm" post, you'll see many of the plants that I have gotten at the framers market.  Kerrytown (where the market is located) has a really neat history, and was created within the city for a village type feel. It's expanded beyond that over the years, in great part due to Zingermans I am sure. No matter what you desire, you can find it at Kerrytown, and the Farmers Market is a must go to spot.

Plain and simple, Ann Arbor is vibrant in the spring and summer. It's beautiful here during this time of year. Main Street is alive, it's (for the most part) very safe. It's a wonderful place to be.

And while it's not in Ann Arbor, Tree of Life dance studio is brimming with good energy, good movement, and truly one of the most gifted groups of woman ever. I have a friend that I met there, and she danced her ass off even when we both felt like standing in a corner might be the easier thing to do. I love her for it, and for the shared "Dear God, what have we gotten ourselves into?" moments.  Go watch them, dance with them, join the Zumba class- you will be better for it.

For horse stuff, the best instructor ever is Cathy Henderson at Cobblestone Farm. I did not get to ride very much the past 5 years, but certainly would have gladly re-entered eventing with Cathy at my side. She is one of the kindest, most honest people you'd ever want to meet.  

Of course, I will miss my U of M hospital friends, and supporters. I loved working there, and that I am not there, well, I never thought that I would end up any place other than the U. Lots of learning, laughter and tears over the years. A super hospital.... and the cardiac units, and the Heart Care Program will always be near and dear to my heart. (pun NOT intended but noted.)

I will miss my few friends that I have here. I don't have many friends, but when I "lock on" oh boy, it hurts leaving.  I have met a few people (and re-met a few) that if I stayed, I think would become very important to me. I am sad to leave that possibility.

The actual graduation day....

Here are a few pics of the day.  Jas and the kids came up (quite a feat with 2 under the age of 3...!) and Lauren and Brad came, too. Very nice to have the support.  And the white coat....

Gary F and I- while he LOOKS serious, it's just an act....
Proud of him!

And the proof that I was some sort of something somewhere 

Finally!

Lots of initials huh?

Brit and Mike

Ana was super well behaved

 And now, onto other things!

What I will miss about Michigan (My Farm)

This was going to be just about missing Michigan-

 but what has become very clear to me is what I will miss is 

my farm, 

my flowers, 

my chickens. 

My house? not so much miss the physical,

 but will miss what I know.

What I know

...what I find important to me is what I know. 

What I can depend on, what brings me joy 

is stability.

 I realize that is very NOT 2012

 that we are supposed to be open to the moment, 

the power of change

No denying change is powerful

No metaphors missed here. 

but, clearly (to me)

 I appreciate the knowledge of knowing

that tomorrow, the sun will rise.

That is what I feel about this land

I know it as well as I know myself 

(which may be in question to me at times, 

so it could be argued-quite fairly-

 that I know my land better than I know myself)

 The garden has not been tended the past several years
Many reasons-

but each year, the flowers continue to rise, and surprise me each year.

I love this view

and as scary as it is, watching Reason gallop up the drive from the lower pasture, 

I love this view, too

But I will miss this land. I will miss the earth. 

I will miss being in a place that seems to know me, and gives me beautiful gifts each year,

even when I have had to abandon it

It's true- I am finally done and a PA-C

This will hopefully be a series of posts. because, well, so many things are happening, and while connected, are really separate. I have had a very hard time separating out the good and the change, from the sadness that has enveloped me at times. I am okay- but please excuse a few weepy moments and emotional tirades.  Hopefully, I can separate it all out.

So, that PANCE test? Eh um ugly times. I figured out 1/2 way thru section 4 that the test was not about knowing the right answer, but knowing what the wrong answers had to be. Very few were clear cut (to me) and often were more "oh, um, well it CAN'T be that, but COULD be this, but probably not...." logic type answers. I wasted a lot of energy on the way I looked at the questions. Bottom line, I passed and got a big old sign to put in my -ahem- office. Maybe I'll care some day? I don't know. I wish I had enjoyed the journey a bit more. I usually do, so PA school certainly threw mud in the face of that.

The end result is I have a job- the one I really wanted- and now that I have it, am scared to death. But hopefully the newness will overwhelm me, and I will get back to loving learning about health/sickness and pathophys and not be so internally stressed that I make the learning awful for me. My internal voice is not so kind!

I have zero idea of my schedule. None. I know I will work some nights, so I will set about finding someone to watch the farm for me when I work nights. I think it will be okay. If I get lucky and get back to backs, I will probably stay in AVL so I can rest as much as possible. I figure that I will work 4 days a week, and eventually maybe 3? I hope. Financially, however, times are- not fun... so I may end up having to work a lot more than I'd hoped for a bit. Again, it's all good and I feel really glad that I am at such a great place, in a great town, and seemingly great people.

I've gotten a few blast emails and they are funny! Seems like everyone has a great sense of humor and I am very excited to get to know them all better. Hopefully they will not be put off by how little I know!

 It's a strange thing- but I am going to emphasis rest for myself pretty soon. This is not a normal state for me- I am usually gogogo. If I do not rest soon, I may regret it.  I think I may out and out crash into a muddled heap someplace if I don't force myself to take a few days out and just not pack, or do anything. Not an attractive sight, I assure you- grown woman in a muddled heap! I've seen it in my minds eye a few times!

Other than that, I am pushing on, trying to figure out what have "value" to me as I pack. I want a very clean house now- I feel strongly about that, so a lot of extra "stuff" is not coming. Thank goodness for Kindle and online resources.  I took a load down last week, and the overlap of my moving in and Jazz and her family moving out allowed for me to really think about what mattered. My room down there has my favorite paintings on the walls, and it makes me really happy to see them. They are beautiful. Of course, of horses.  I do love the sheep picture above that I found in Burlington but did not know the results of the boards, and again, being financially responsible I did not get them.  Maybe later in the summer??

Okay- 2 more important posts to go!

pa school...done!

The two years are done- not like it was a breeze, but I admit being somewhat shocked that it’s done. The news has not “hit” me, or my inner me just yet- I am still waiting for the phone call, the notice in the mail, the certain something that says “No, you’re NOT done, you forgot X,Y or Z and you failed this, so sorry, no graduation for YOU!” I think it might hit me some time next week, when I am driving to get Nick in Vermont. Maybe then? I think I will probably need to stop, cry a good long time and then shake it off. 

I have not been the most stellar student- my class was filled with those. I was average. Smack Dab in the middle for most of everything. I think in the end, I was just that- and I am okay with that. I am not a chief, but am a very happy Indian.  Perhaps this is why I can look forward to being a good PA. I want happy, well taken care of patients. I am not a headline kind of person, but really happy to fly just under the radar, no waves.  

I actually really love patients. I am scared a huge big great deal about the next aspect of my life- lots of changes, but overall, the idea that I might make a difference in someones life, in a real way, is very exciting to me. (I add because my heart did indeed skip a beat or 3, that it’s as likely to be in a not-so-great way as I learn what it really means to practice the art of Medicine....)

I am excited about my job. It is in Asheville, at Mission Hospital in the ED. Scares me, yes indeed it does. But I am okay with it. I think my new boss might just be amazing. I only met her for a quick interview, but wow...she is one of those smart, savvy kind of women that make me darn excited to be working with her. My biggest fear is letting her down. I had several phone interviews, but when push came to shove, this is what I wanted, and I am really excited that I am heading there. Start day is June 11. 6 weeks from now. Very soon. Very very VERY soon. 

So, its done. The next post, which needs its own page and space is going to be about preceptors. Because, they are what made me ready for this next step.

A more personal post....

So, today marks the 29th of Feb. I am oh-so-happy to have this month gone and done with. It's been a doozy.  So, just because sometimes it's nice to mark what HAS happened, in order to see that things DO pass, I am going to write about them.

So, Arts surgery (and please, read this all the way because sometimes in the storm, the clouds are QUITE dark...and we all know that the sun does come up as soon as you look up to see it!) took place on a Monday.

 It was robotic, and turns out, damn good thing that A) Art decided to get it done despite the delay with the flood at the Cancer Center happening in January which led to him  not actually meeting the surgeon before scheduling and B) that they allowed this to happen. Turns out this puppy was not a slow kind of growing cancer, but one that was aggressive- more so than they thought.

Staging changed which was the news I got about 4 hours into the surgery. Dr. Miller said he thought that he had gotten all the margins, but nerve sparing could not happen. This can be devastating news for any man. Google it.

Because even if you prepare and talk it out, sitting there, talking to the MD really kind of puts it out there in black and white. It's no longer "a story" but an "Oh Shit" kind of moment. Because as any good PA student can tell you, those two years of school, you put a lot of crap on the back burner to deal with later. This was no longer later, but now. And it hit me- Hard.  Embarrassingly hard.

Art came out well, and was groggy, and Sa02s were a bit low (snoring does that to a person) but overall, seemed okay enough

So, I had been texting Stacy throughout the day, who was dealing with her own "stuff" and she kept me sane. Sadly, I elected to NOT buy the Hello Kitty purse that I texted numerous pictures to Stacy of from the Gift Shop, and I think I ate my own weight in Chocolate and Starbursts instead.

I ran my phone right out of battery. So, since I had NO gas, nor battery, I got into my car, thinking a nice drive to get a charge and a change of environment might be nice. I plugged in my phone and got the (expected) numerous VM's which I assumed were asking about Art. I saw one, however, that worried me, because it was from the person that boards her horse at our house. It was short and sweet.

"Call me when you get this okay?"

I got a text a few moments later, and it said the same- and I missed the bottom line of "the horses are okay" which was my biggest and greatest concern. So I called, and found out that the LAST thing I ever expected to happen had indeed happened.

Some lovely person decided that they should break into our house.

Yup.  Today.  Since I don't even own a KEY to our house, they thought kicking in the front door was a great idea.

So I have no more to say about that (Other than HUGE thanks to the observant folks that saw the door open and took their time to stay at the house, call the police and try and hold my very unholdable parts together and know to answer the phone when I called by saying "The animals are okay".)

That was a LONG DRIVE HOME! and despite the fact the day was rather warm, I was rather cold. I was tired (I had worked the previous night), and my eyes hurt a lot from crying.

Despite telling the RN"S to tell Art that they told me to go home and rest as I knew he would wonder and be concerned, they didn't actually do this, and he was beside himself with worry. So, despite my best intentions, and my desires to not tell him, him knowing that I would have been there if I could have been coupled with seeing my rather swollen and red eyes made that impossible. So, I left him after telling him (and helping him push his PCA a few times!) and told him I'd be back in the AM.

 I spent the night at a friends house, who knows me better than I think almost anyone does, and I just curled up in all my clothes and fell asleep.

Farrier in the AM, and little sleep, but got the horses done, barn done, and off I went back to get Art. My eyes, however, preferred to NOT be open, and they, come to realize, still hurt a lot.

Did you know that you can scratch your corneas by crying?  I am here to tell you that, yes, yes you can. And Yes, yes I did. Good enough to show up on staining. Across the visual fields. Special, huh? The ED at the U was VERY kind, and I did NOT steal the numbing drops, and best of all, got a hug from my preceptor who works in the ED.

I was a proper mess. I didn't like me. I was GROSS. I was a psych patient.  I was doing everything except saying I was allergic to Tylenol, Motrin, Sulfas and looking for some drug that worked called "DyLayDid???"  No, I just was "that" patient, that had hit her breaking point in an unfortunate place called the ED. But the RN's made it clear, I was NOT driving until someone checked out my eyes. So I obeyed.

But guess what? My kids are A-Maize-Ing. (intended...more on that soon). Nick and Jazz conspired, and between them, and not listening to me in the slightest (bless them), Nick flew home from Vermont the week before midterms. He arranged every thing himself, got food for the house, helped with the horses (this is huge!) and generally just made me smile, rented movies to watch on the computer (we do not own a DVD player and turned off cable a few months ago, and internet is thru the cell phones) and kicked my ass in Yatzee. Honestly, even now, the sheer kindness that my kids have just astounds me.

We found out the next day that my mom, who is on Coumadin fell and hit her head and broke her nose in several places. Thankfully, she is okay, but did have surgery the following week- normally I'd have been there in a New York minute but there was just no way. I have yet to miss a rotation day, and damn, since this was THE rotation, I was not going to start that now. I had my 4 days off (scheduled and I arranged shifts to allow for that) and I knew she was in good hands.

Several more annoying things happened, all connected in some way to each other to create a chain of "ughs".  But...

Today... I can laugh a bit at it all because-

Art is doing SO much better than anyone could have ever expected. Yes- margins were clear and nodes as well.
Nick not only kicked A** on midterms, but finally heard and is now a U of M student starting Summer 2012.
My mom sounds great and is doing well!
 I got A's on my last 4 rotations. I have heard back from the NY ED residency program, so that might be on track, and have a job interview at the UMHS, and remain hopeful that EPMG might offer a fellowship again in ED for PA's.
I had a great meeting with my program director that instead of being the dressing down I was convinced I thought it must be, instead turned out to be a huge moral booster, unexpected but oh-so-nice.

Finally, our sweet "White kitty" Lucas, who has been quite sick, remains alive, and holding on. We are not sure what his deal is, but he is quite sick. Hopefully he turns the corner- but I thought last Thursday that for sure he would not be alive today. He is. The vet remains totally baffled. But, he is thus far still here.

There are a lot of great ED stories to share, and moments that make me SO happy I am on this path, but Adios February. I am more than ready for  March, despite turning 50!

Another flower added

Last night I worked with my next amazing PA. EPMG has a roster of impressive, bright PA's that bring a lot to the table, including their absolute willingness to teach, impart wisdom, pearls and other delights that bring me to a new level of excitement about becoming a PA. I was lucky to get this rotation, and I am thrilled being there. I count down the days, not because I am looking towards the end, but because I am sad that it is going to end.

My first two patients were easy ones. I made the DX, and it was quite simple. Reassured them they were not going to die, and off they went, hopefully relieved. Since the rest of the ED was hopping, I felt a bit like a good luck charm. Ah, the joys of being naive. ;-)

My third was a young woman who was placed in a hall bed. Ah...not a good thing for anyone. Complaints of N/V, general exhaustion. Her history reveled that she had missed her last period. Further questioning also indicated that her mom had died less than a year ago, from HIV. No smoking, drugs, ETOH herself-mom contracted HIV from a boyfriend a few years ago and the disease progressed rapidly.

She was living in her moms house, taking care of her brother who was younger than she was. Simple math showed that her brother was a minor when her mom died, herself just barely into adulthood. Dad was long gone. She had no other relatives that were involved in care of herself or her brother. She had insurance, and worked at a nearby fast food restaurant supporting them both. She was an example of an upstanding citizen.

And indeed, she was 6 weeks pregnant. I sat next to her, and told her the news. I asked her if she considered this a good thing, and she nodded yes. The supervising PA ordered the rest of the tests, and all came back fine. She was given prenatal vitamins and we spoke a bit about good prenatal care, and the importance of this. Her boyfriend was steady, a good guy, looking for work. When I gave her the results of the ultrasound, her bottom lip trembled slightly, but the joy on her face was not able to be disguised.

She was scared, but happy. She clearly realized that this was major, life altering event. A beautiful girl by anyones standards, she somehow emanated that internal strength and courage that some just have and can draw on at the right life moments. She was drawing on it, and it was doing her well.

When it came time to discharge her, still in her hall bed, I hugged her and told her that I knew her mom was watching. She said that she thought her mom probably knew and wanted it to happen. She said her mom was a great woman, a wonderful mom, and she missed her a lot. I got her email address, probably the first and only time I will ever do so with a patient.

Another patient that I will never forget, another flower added to my lifes bouquet.

Some PA school truths.

1)I am behind. I am ALWAYS behind. I have not logged every patient that I have seen...not even CLOSE. I lost a lot of info, and E*Value was not able to retrieve it. Oh well. I am behind.

2) Kevin has finally turned off the ability to log patients that we saw 6 months ago. This should worry me. It does not. I am relieved. Can't do anything about it now, can I? How many sore throats can I log?

3)seriously- sore throats are just that. Sore, Some need meds, some don't. Clinical judgement. And I fall onto the SNAP side of things (Safety Net Antibiotic Protocol) because I'd rather not give  antibiotics if I can avoid it...stewardship and all that jazz.

4) I am almost DONE!  This is a good thing. Both for me and the program. I have pissed them off, esp the newest staff member. I am not one to piss people off very much, but clearly I have pissed them off because I have tried to find my own rotations.  This has not gone over well at all. Lead balloon like not well.

5) BUT! This is how I found my most current rotation. My preceptorship is in Howell at the ED there. When I told one of the PA's that I am working with now that I was going to be there, she said it was going to be excellent. Kevin said that it would be excellent. So I am feeling excellent. All good.

6) Seriously- I am glad that PA school is almost done. I don't feel ready to go out and do my thing, but thats probably SOP. So- onward into more learning.

7)(Lucky #7)  I am applying for jobs. I also am somewhat hopeful that I might be able to get a fellowship at St. Joes.  I have also sent in an application for the Rural ED residency in NY (Which was my intention from the very beginning). They have not emailed me back despite several emails to them. Don't think this bodes well, but....  next post? What I want to do.

(MY IDEAL LIFE...In Tryon, working at St. Lukes.  ED department. It's out there now.)

Online blogs, podcasts, and other really neat things to have at your disposal.

I am blogging this, because there are a few places that are my GO TO places on the web.

So, First- Podcasts....

A Gobbet 'o pus  Mark Crislip  who would be the first to say the world needs a more of Mark Crislip...  Mark is an ID doc, and he podcasts about 2 times a week. Great quick listening. The beginning ones have a lot of sound effects that he has removed from the most current ones. I liked the sound effects for the first 100 or so. Now, I appreciate just listening. He also has an app that I use a lot, as well as a QuackCast that I have not explored yet. Sure to be soon.

Emcrit- just spectacular. Always has a bevy of show notes that I refer to. This is geared to the ED /Critical care MD but I still find it great to listen to. Usually about 20 min long. Great Manny Rivers MD of Henry Ford Fame and his sepsis talk. Saved my butt a few times!

ERcast- another one that just is easy to listen to- lots of everyday, important info'


OOPS! Never finished this post...will do so later!  But for now, enjoy what I have listed thus far!

Babies...

This is not going to be an "in order" post, because I am really behind (and yes, I was taught do NOT start anything with an apology but I am starting this with one because clearly I didn't listen.)

I am with Dr. Mason. I was told (perhaps warned??) that I was going to love him.  I do. It is one of the best rotations I have had, just because his patients adore him, he gives them every second they need, and he gives us every second WE need. How many people can do that? A lot to look up to and learn from.

First day? A lovely OP vaginal birth. Since it was my first birth that I was not...um...being the center stage of, it was interesting. And beautiful. And the baby was perfect. Hard birth (OP means, at least from what I a can tell thus far is that is it going to be hard, and pushing a face up baby is often REALLY hard.) But she did it with a lot of coaching.  I am pretty sure I was more happy than she was at that point in time.

Monday brings a lot of scheduled births that are from high risk moms. Several were from clinic patients that we saw on Friday. I am very glad I get to see those births. I am really excited and I must say that being a part of bring life into the world is just...amazing.

There is a lot more to write, and I think I will be writing a bit more "personal" stuff soon, because a lot of personal stuff is happening. Not all of it's good (ah- a very atypical Annika Sentence!) so deserves a bit more explanation. But that will come next...

The LOL Surgical consult

Call nights are long- often filled with incredibly boring periods, peppered by intense moments of trauma codes. This night was no different,  we had more ER consults than trauma codes. A good thing for the people involved, but for us, at hour 19, well, a bit of trauma does the exhausted body good-caffeine? Ha! No need with a healthy dose of adrenaline- stabbing, gunshot or 3, housefire with a pregnant woman- that'll getcha going.

I got a consult on an older AA woman. She had an abscess- but it was not specified where. I have learned that getting in on the bread and butter cases, the ones that the interns and residents don't want, are the ones that I want. I can DO them- and learn from them. 

I did my H & P. the history revealed no major medical issues. No surgeries or injuries save a broken tooth or so. 3 kids, all normal vaginal deliveries. +FM of the typical DM, CAD, HTN- but thus far, she had none of the above. Did not smoke, drink, do drugs.  No waving red flags.  Okay! I can DO this! So, her issuse seemed to be just isolated- painful and isolated.

This poor, tiny 78 year old woman had an abscess on her mons pubis. Big one. Denied waxing, was not sexually active.  She was married, but her "man" had been living with another woman for the past 20 years. She was a-okay with this. No one else in her life-lived alone.  She did call her husband when I was interviewing her to ask him what other meds she took- Vit e was pretty much it.

The PE revealed she had the worst...um...well, yeast infection that I had ever seen, and honestly, guys, hope never see again. It was..."impressive". Put that in your admission note and that'll catch someone's attention. As I said, she  denied DM, however, just as I was beginning to ask all the questions, leading at least my differential that such an infection tends to come from in a woman who denied ever being sick, the RN pops her head in "Her BGL is 511". As I was being told this, she was grabbing her Big Oreo Pack out of her purse to munch on. I told her that Oreos are probably off the menu for a bit.

At least I had one answer to one of her problems.

Clearly, however, the other issue was going to be done in the OR. Poor thing. She had a red, hot, fluctuant mass, about 6cmX10cm.  It did not go thru to bone from what we were able to assess in the ED.

 Here is where it gets funny.

She had never been in the hospital. She wanted to take EVERYTHING home- the empty IV bags, the chucks, her phone was out-she was snapping pictures everywhere. I have one of her-she wanted to have one of both of us on my phone too so I'd never forget her. (Not like I could forget her...).

She was so cheerful, so optimistic, and upbeat. She was sitting up in the OR when we got in, talking to everyone a mile a minute. I am sure she was nervous, but none the less, a truly bright spot in the rotation for everyone who touched her that night.

Later, I found out she had been putting Icy-Hot on her "'fected part". I came into her room for her post op check and she had it out to apply it to the open drainage area.  I can only imagine the pain that would have been. I had asked her on initial interview if she had done anything to make it feel better, I guess I needed to ask if she did anything to make it feel better that failed. That I would consider a fail to be sure. She then admitted to putting cabbage compresses on her "'fected part" too. Her post op went smoothly- her BGL were labile as would be expected, but medicine did their magic and they were eventually controlled.

And now, in all the ways that so many of the rotations went in Detroit, her story is so much deeper, sadder and still astounding to me.

Frankly, Sad.

Remember that phone? All those pictures? She had a chronicle of her life in pictures on her phone. If anyone ever got her phone, the things that they would see. She could hardly see her phone, but she took pictures still. When she was showing them to me, about 1/2 way back was a picture of a man in a casket.

 I was taken aback...what in Gods name did she have that for?  I asked of course (I always ask...just my nature). She knew him- he was her neighbor. He had been shot, in front of her, outside her apt. And yes, she had pictures of him on the sidewalk, dead. She knew who shot him.  While telling me about this, she covered her mouth, asked if she was going to Hell because she had lied to the "Po-lease" because she knew that if she admitted she knew, she might be next. You don't live that long on the east side of D-Town if you're a dummy. She clearly is no dummy.  If there is a God, this woman is certainly not going to Hell. She has been there- but her cheerfulness and joy in the world was bigger and greater than what surrounded her.

She said she had pictures of all the people she had seen at funerals. All her friends kids who had died. All the people in her building who had been shot and killed over the years.

She told me that she slept in front of the window now, watching to see if anyone was coming. I am a white girl from the country and I have one thought about guns besides ban 'em. I want FAR away from them- esp if someone I don't know is carrying them.  Her thought was that if she saw who was coming, she could get away. She was scared but it is what she knew. Me? I'da picked a door. A solid door.

I don't remember her name, I have her picture still. I hope she is okay. She was discharged home after 2 days stay to get her glucose under control. I hope she followed up- and I hope that somehow she has found some peace and quiet in her life.  Yes, I asked SW if they could somehow help, but no- nothing to do. She was A&OX3. Frankly, she was a great example of survivor, strong, beautiful, an optimist in the light of all that is so difficult about D-Town.

This happened well over 2 months ago. I am ending my stint of being in Detroit for rotations. Overall, I have gained such an appreciation of the deep recesses of humanity that exist downtown. Yes, it's a terrible place, but under the layer of grime and filth, there really is something very special about the city. The grit, the simple acts of survival that profoundly effected my rotations there. Certainly I learned something about medicine or at least I hope so, but I also learned a lot about people. I actually do believe that the city can be brought back.

There are a lot more stories- more blog posts to come. It's a lot of driving to get to and from- easy 2 1/2-3 hrs a day. I won't miss that! Makes for no time to write anything. A2 next month....

The entire patient

is what we treat.

A pt came in to us. Seriously hurt because they had done something stupid when consuming a bit too much alcohol. Well, a lot too much, really. Lucky because no one else got killed. He hurt himself worst of all, but his companion will be feeling the pain for days.  He ended up being surgical to fix some seriously broken bones in his face.

(you ortho-gods, bones, bone fragments, breaking bones, moving bones-def not for me.... I give you credit.)


As a good PA student, I researched his EMR thoroughly. It had been mentioned that he had an ID band on his wrist from our hospital when he came in. I asked him when he was alert enough if this was so, and it was indeed the case- he had been DC'd just a couple of weeks before.  Shocking- admitted for another trauma that was associated with ETOH. And further back, in the past 6 months he had been in our ED over 6 times. Not always admits, but always trashed.


Each time for ETOH abuse/issues. Levels were all over 200. Each time. Some MUCH higher. And most of these incidents were involving a several thousand pound vehicle traveling at high rates of speed. Anyone seeing any red flags?? I was holding his hand, and thinking how much he had cost our system, how close he has come to killing people. According to his EMR, he would spit at MD's when angry. None of that right now, he was a scared kid.


He was younger than my daughter, older than my son. I talked to him about quitting. He said he wants to, but he tried and he couldn't do it alone. I told him this meant NEVER drinking. He said he knows. He said he wanted that. He wanted rehab. 

I accompanied him down to the OR later. He was polite, we kind of knew each other at this point in time. I admit still being irritated with him, and feeling cynical- he was driving without a license,  he was responsible for several other injuries we were treating that day.  What made me think my simple little "You GOTTA stop drinking before you kill yourself or someone else" talk would make any sort of dent in his disease?

A family member was escorted into the room to see him. It was a woman, who right away went to his side and started to rub his back. I introduced myself and she told me she was his grandmother. She asked me a bit about his injuries, and what to expect. I reiterated to her some of what I knew, and what I had told him- his physical injuries were serious, but the most important thing was that he must stop drinking.

She looked right at me and said "He has to learn to love himself first, then the rest will be easy. I want him to get through this- he has a lot to deal with when he gets out of here. My only concern today is that he knows he is loved, and that he is loveable, and that I am here for him. That's my only concern today for him today. The rest will come."

She proceeded to tell him some of that, and I watched her bend over him, whisper to him, rub his back. While he was in and out of awareness, she told me a bit more about him.  She was his dad's mom, that his mom was not a loving person, and that she had said to him after he had come into us that she wished he had died. Her son just had been getting help with an addiction to drugs. "He's stepping upto the plate- it's taken him a long time, but he's here."  Her grandson had worked for the city but had gotten laid off with the latest cuts. When telling me the background, we both were teary. She then prayed over him-for his recovery, the surgeons hands and the calmness that is needed in the OR to make her grandson better. Her faith, despite mine being questionable, filled that cubicle. It was bigger than anything else in that hospital at that point.

His mom came, clearly inebriated. Grandma left then, so the rest of the family could come in.

During his post-op check, he was doing very well. He responded well, wounds looked great. I told him that his grandma had been there- and what a remarkable woman she was. He said he loved her.

I then told him this: To have someone love you so much is a gift. It's a gift very few have. It's provides more riches than most have. It may not put food on the table, but it puts something into your soul, your heart that is just not possible to reproduce. It's not something one should ever take lightly, and indeed it's a kind of responsibility to know that someone loves you that much.

For me, it was a reminder. A chuck under the chin to remember that the story is far more than the EMR might indicate. It's complex, sad, heartbreaking. But there are threads of golden woven through that glint thru the ugliness that permeates so many stories we see. Keep looking for the golden. You might find it.

I'm glad you're here....

Yesterday I observed a surgery that was not performed by one of our surgeons, but one from another service. We had had this patient for as long as I have been there, and has been my patient since getting to our hospital. I asked the if I could observe the day before, and was told to page the attending to ask.

I don't do that. Call me chicken if you want. I'll take that rather than the wrath of an irate attending that is about to perform miracles in the OR on a patient I care about. I want that attending to be in a really good, balanced mood when they take that blade into their hand, not irritated with a student-much less a lowly PA student.

So, I went down to pre-op with the pt and waited for someone who knew something about anything. The resident showed up and I asked him when the attending might be there. He said..."I'm glad you're here. I already talked to him about it- he's cool with it."

I admit- I got a bit hot and bothered. In a good way. Those words made my day. Quite possibly my rotation. Not one other person has said that to me since starting rotations;I miss that feeling of being a valued part of the team. Even as a tech, the RN's would comment on my being there- that they were glad to be working with me that night. I know I make a point of telling people that their presence is a good thing- that I appreciate them caring if I see them do something above and beyond. When teching, I have even emailed a RID (Really Important Doc) and said how much I appreciate their care of a patient. That might have been a bit too "annika" but I don't really care.

So, thank you Dr. C, you made my week. I stayed late to watch the surgery, but instead got a boost of needed energy.

Surgery

So, as I said in the previous post, I am in surgery.  I am surprised to say that I love the ED part most of all. I mentioned before that I had considered a residency in ED- one focused on Rural medicine that is in NY. I kind of dropped the thought off of my local radar, just because A)money-I need to make some of that green stuff and the sooner the better! and B) thinking that not having the continuity of patient care might limit my enjoyment.

 Nope. Not so. It's actually good- I can care, and deeply care, about getting the patient better enough to get them to the next step of their recovery and that is good. I love the intensity, the need to bring all aspects of my (limited) training to the forepart of my brain, balancing the medicine, surgical aspects in the resus bay. I of course am watching and learning right now. But, my head is swimming with thoughts.  

So, the thought of the residency is back. Strongly. I think it might be great. I think I might like it. And since nothing else has really grabbed me yet during rotations, maybe this is it. Stay tuned.

I also admit feeling like I have not learned nearly enough thus far in my rotations. Not nearly enough. I also admit that I wanted to be at UMMC for many of my rotations. Thus far, I have gotten none of them. Zero. I miss the U, miss the environment that that place provides. There were endless opportunities to learn there- endless. I miss that a lot. I also miss the caring that the U seems to have at the center. I am not seeing that out in the "real" world, and I find that sad.

So help me GOD....If I see/hear of another person slamming a NG tube down someone, without lube, and hurricane spray--forgetting lido-jelly even for a moment as a possible assist-and then wonder why the patient was so miserable and refusing another NG tube, I wish the NG curse on them some day. Because when I asked, I was told "it takes too much time".  Oh boy...If I were not a student, and somehow could mention what I really thought, they'd get an earful.  Say whatever you want, it's the wrong thing to do.


I have seen several surgeries but none of the usual suspects...no appy, lapchole, bowel obs for me! Nope, was in on a massive lac to the back of the neck where the C-spine was...right... there...and the clot that had formed was as big as a small baby. I kid you not. I have seen orbit repair with screws, plates, mesh. I have seen more I and D's- seemingly the bread and butter of surgery-forget hernias! I have seen an exploration of an orbit from a possible self-inflicted GSW...I'll tell that story at another date. 


I have learned a lot I admit. Most of what I have learned is this: 

• Who you work with is as important as what you're doing
• Driving over an hour to work is plain and simple NOT for me
• I need to be someplace where patient centered care is at the fore-front at all times
• I need to be someplace where you're striving to always be better, so the patients get better
• I need to always be able to learn, to push past what I get and enter into areas that I feel lost and need the compass of those wiser than me to survive and thrive
• Saying I don't know is okay as long as you make sure you will know soon

Till later. I have a hot date with First Aid and Surgery Recall, never mind Casefiles!

The rotations keep rolling

I am currently in my surgical rotation. Parts, I love. Parts I dislike. I have seen a lot of what I do not like in me coming out- dealing with one of the team members is quite challenging for me. I have 2 more weeks. I canwill be nice, and think good thoughts about this person and know at the end of it all, I would rather have me than that person taking care of my patients. And if you "know" me, that's saying a lot.

I finished psych. Outstanding preceptor, but horrible rotation. I am rotating in an area where despair is the norm, and the genetic pool is riddled with mutations. Psych is a hard one for me, because we can't fix it. Not one bit. Our meds might make a difference, but does it really change the illness? No, it'd be a fix, but not a change. In many ways, it's like a cancer, but a never-ending-never-changing sort of cancer. Lifelong CLL. But worse. I admit wanting to fix things, to make things better. Inpatient psych, esp as a consult service really can't do that, nor does it pretend to do this. Perhaps that's why there are so many tools and ways to pigeon hole the patients. A DX is essential, and knowing what their GAF is becomes important. How does axis III change axis II?  I? Perhaps intellectualizing all this allows for the MP to keep some distance, and allows for better care. I don't know, and I know that I am not going into psych.

That's okay. I am ok with that- there are so many things I want to go into, ruling one out is in my best interest right now.

A rather nice week at the office

On the "interesting cases" kind of note- Saw an honest to God spontaneous Pneumo ("Large" according to the radiologist...wish I could have seen the films, to correlate PE findings with visual understanding).

Yes, Tall, skinny kid. But No SOB, nor any other serious "OH DEAR GOD" signs. Just an amazing MD who caught it during (yup) a routine PE. I'd bet that the kid was kind of miserable and made the appt. He had not been in for 3 years.  I did notice fairly pink (red?) cheeks, which I remember seeing in my CO2 pts before. No ABG or BG to see, I am sure they did that at the ED. I'd also like to have seen that, but honestly, I am hoping it's venous, as this kid was already scared enough. Just writing about it gives me the heeby-geebies. My biggest issue is knowing that he might be in for a world of pain. And, came into the office without family attached to his side. In his car.

Ugh.  But nods to an amazing peds MD who A) Caught it, and B) called me in to hear it. Did not say "This is what this is" but let me listen, and think. What I heard was cracking, and "far away" sounds on auscultation. Only way I could describe it.

Mrs A

I had not been back at the U for long, so had not acquired my ICU shoes all that well yet when a pt entered my life in a way that few patients ever will.

She was on "the list" and had been several times. Each time, you get to "stay on" for a certain amount of time, and then, get taken off, moved out of the ICU (usually at least), have another full work up, and get re-listed. This happens several times for some patients, and it, I am sure, is most frustrating. Our unit remains one of the few that have not been renovated to the degree that being in the 2010+ years seems that it should be- and whomever designed the rooms clearly had never taken care of a patient that was on precautions. 


Mrs. A had done the List Dance several times by the time I had really gotten to know her and her family. She had a devoted husband who kept her laughing, and family that cared. She was lucky that way. What she was not so lucky in, however, is exactly how sick she was. Obviously, being on the list meant something was seriously wrong, but also she kept getting those little annoying nosocomial infections. Okay, that is a huge understatement; she never came down with one of the Big Ones (MRSA, VRSA, C-Diff) but the ones that take one off the list but aren't that terrible to actually have.

Her husband had left for the evening, and she called me into her room. I asked her what she wanted and she said "I don't want to be re-listed". It was more than that, really but the end result was she was done. She had had it, and just was tired. At this point, she thought she had been in the hospital for about 6 months. I called in our Fellow (after explaining that I was not the person who needed to know this, but someone that might be able to actually DO something about this needed to hear this from her.) We all cried but clearly, we all understood. One can only take so much. Her reason for staying the path thus far had been for her husband- as I remember it, she said she was really ready months earlier, but she knew he would not want her to make that decision. I was not there the day of the family meeting, but clearly, when one loves as deeply as they loved each other, the decision was made.

Problem was- she had to stay with us. Her meds were not ones that could be stopped quickly and she could not be D/C'd to hospice on the meds. So, weaning began. She did well, and things went as smoothly as can be.

Mrs. A comes back to me a lot during my thoughts of special patients. But this weekend I had a very special Mrs. A moment. Ann Arbor has a lovely thing called Top Of The Park where local musicians play. There is some serious talent in the area. A man named Levi Johnson  and his band played this past weekend. As I am wont to do, I began to dance- his was a funky, motown sound that makes even the most tired of feet move. He began (as a black man) to sing "Play That Funky Music White Boy" which brought me back to the last time I saw Mrs. A.

I asked Mrs. A what she wanted most of all and her answer was some good music. Her husband was there- and I asked what that was exactly. I was thinking my Jack Johnson and Michael Fronti might not be it.  I was right- They wanted some good soul or funk-  70's type music like- oh- "Play That Funky Music White Boy" So, thank you to  iTunes, I downloaded a few songs, we closed the curtains and turned the iPhone up as loud as we could  and danced. Well, she moved in her bed and her husband and I danced. I remember that moment, and knew then that this was to be one of those moments I'd never forget- a white woman, in scrubs, in a tiny ICU room, dancing with a black man, and his wife moving as best she could, to the sounds of Motown.  I realized  then and know now, how absolutely lucky I am to have known them, their love, their courage.

Mrs. A died a week or so later. Her husband was there as were a few of our nurses that went to stay with her at the end.  Someone posted a picture of her before she got ill- and she was startling in her beauty. The thing was, I saw that beauty from the inside of her, and it remains one of the most beautiful things I have ever known. My memory of her lives to this day.