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

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.

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....

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.