I've just begun my second week of this rotation. I enjoy my schedule a lot, I only work three days a week, and I do 12 hours shifts (which are very very doable considering how many hours a day I spent at school during didactic). I've pretty much worked with a different PA for each patient (there are 18 I think on our service?) so it has been good experience seeing how different people do things and approach patients.

Yesterday I actually saw two direct admits, meaning they were admitted directly to the hospital by their doctor instead of coming through the emergency department. The first was an older woman who had blood work drawn two weeks ago that showed a hemoglobin of 9.?. Then she had is redone a week ago, and it was 8.4, and then yesterday it was 8.2 (a normal hemoglobin for women should be up over 13). Obviously she was bleeding somewhere in her body, but she actually didn't have any other of the typical symptoms for anemia, other than a little fatigue. She did mention however that her stools had turned a darker color--that means that she was bleeding somewhere in her upper GI tract as she had enough time to digest the blood. Most likely it was a perforated peptic ulcer. She is scheduled to have a scope done of her upper GI tract this morning.

My next patient was not a direct admit was a very lucky 71 year old man who had been having crushing chest pain for a week. He was stubborn and wouldn't let his wife or daughter take him to the emergency room. His daughter is a paramedic though, so she made him take aspirin and nitro during his chest pain episodes. They didn't help however. We took him in today, and his EKG initially was fine, however he had peaked T waves in four leads, which the cardiologist interpreted as a very very very minor STEMI (heart attack), however there weren't reciprocal changes in the other leads. It probably would have progressed to a full STEMI though. I followed him up to the cath lab, and they let me watch both his procedure and the one being done before his. When the doctor went in, he found a 90% occlusion of the left anterior descending artery (the one they call the widowmaker for a reason, it's the most deadly artery if it's blocked). He was basically a cardiac arrest waiting to happen, and who knows how much longer his heart would have been able to hold out if he hadn't finally made it to the hospital. They put in a stent and voila, the blood flow was back to normal. It was interesting to see how his blood vessels had remodeled due to his hypertension (and the nursing working the monitors explained that it even looks like he has uncontrolled diabetes, the way the vessels looked).

A cath lab basically allows a cardiologist to figure out where blockages are in the artery of the heart by injecting dye that can be picked up by an xray machine (in real time). They pass a wire up through the femoral artery and they can get different views. In the case of this patient, they were able to blow up a balloon once they found the blockage to widen the vessel, then put in a stent (a special metal device, kind of like those chinese finger trap toys) that will keep the vessel open so the rest of the heart can be supplied by blood. Pretty interesting technology. The stents are usually covered with anti-clotting medications to help prevent any further complications in that artery. The patient does have to take Plavix for the rest of his life though if he wants to avoid deadly clots forming around the stent.

I spent 4.5 hours in the cath lab overall, so once I was done I only had time to see one more patient, my second direct admit. It was funny, this weekend I was going over all the diseases I need to know how to manage by the end of the rotation, and I said to myself "I'm probably never going to see some of these." Sure enough this patient had one of them, thrombotic thrombocytopenic purpura. He developed purple spots all over this body two days ago, and then the next day developed large blood blisters in his mouth. He did not have the typical pentad of symptoms (most people don't actually) but it was interesting getting to see a disease I might not see again!