Exposure to new techniques or treatment strategies – how did that go?

On the first day of this rotation, I performed my first ABG. The PA I was following congratulated me on getting it on my first try, which I found very encouraging, as it was nice to have been met with such enthusiasm. I was also called to help with an arterial line, which was a new experience for me. Another PA also showed me a systematic way of going through a chart. First, he started looking through the ICU Summary Accordion, where you can set the interval to 8 hours and assess the trend of the vitals, labs, and results of any imaging or procedures performed. After the ICU Summary Accordion, the PA instructed me to look through the Chart Review to see what medications or fluids the patient was on, followed by Orders to assess what is still pending or to be administered in the future, followed by Notes to see any notes written by the PA or MD in the ED as well as any consult notes from specialists, such as cardiologists, pulmonologists, or nephrologists. I also was able to practice submitting orders and writing discharge summaries, the latter of which took time but was important in terms of providing pertinent concise information for follow-up providers, such as PCPs, who will see the patient post-discharge.

Managing new types of patients and the challenges that arise from that.

During this rotation, I was able to spend one week with the stroke team. As such, I learned a lot about the management of stroke patients during stroke codes, consults, and rounds. For instance, during stroke codes I really learned the importance of collateral information, especially last known normal behavior / activity. It was really significant during one code with a patient who had also been showing signs of dementia prior to his stroke symptoms. His daughter was able to provide an extensive history of his symptoms, both acute and subacute, which ultimately aided in the proper management of her father’s care. During my week with the stroke team, I completed the NIH Stroke Scale certification and was trusted to complete the NIH Stroke Scale for two patients prior to their discharge. A challenge I experienced with performing the scale came when I needed to complete it for a patient whose primary language is Cantonese. The NIH Stroke Scale is only in English, or at least the only version available to me, so it was a challenge when using a translator. Some of the phrases to test for dysarthria were not similarly translatable per the translator, and repetition of the phrase in Cantonese became the way to complete this part of the stroke scale. Such an experience was a great example of the many ways cultural competency plays a role in the management of patients.

What was a memorable patient or experience that I’ll carry with me?

One experience I will carry with me from this rotation is from rounding during my week with the stroke team. The PA and I had seen a patient whose granddaughter was present visiting her after she had a stroke. The patient was not at her baseline still recovering, but her granddaughter was by her side the whole time holding her hand and trying to communicate with her. It reminded me of my own personal experience with my grandmother when she was in the hospital when she was sick, an experience that informed and reinforced my decision to pursue a career as a PA after I had spent so much time with her in the hospital.

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

The knowledge I have gained from this rotation can be applicable in other disciplines as internal medicine provides a strong foundation for every other specialty. For instance, many patients admitted had CKD, and it was thus important to determine appropriate renal doses of medications based on their GFR. I also learned that certain lab values, such as procalcitonin and pro-BNP, are not as accurate in ESRD patients. Additionally, I also learned about age-adjusted D-dimer, which is a patient’s age times ten. This was not something learned during didactic so learning it clinically during this rotation is definitely knowledge I will remember for other disciplines. I also learned that procalcitonin is a marker assessed in the setting of bacterial lower respiratory infections, and beta-hydroxybutyric acid is checked for patients with insulin resistance and with DKA. Moreover, I learned that ferritin is a lab found to be elevated with COVID patients, which is new knowledge that can be applicable in any setting where there is suspicion for the virus in patients. Lastly, I learned the indications for telemetry, which include to rule out ACS, chest pain, or NSTEMI/STEMI; acute CHF exacerbation; acute CVA/stroke work-up; significant electrolyte abnormalities; new onset arrhythmia [not old or chronic]; and syncope work-up. These indications are important to keep in mind for specialities, such as the ED, ambulatory medicine, and family medicine, where such diagnoses may present.