Just.....bored.

So it's been almost three weeks since my last post, mostly for two reasons:

1) I go to bed before my 3 year old nephew because I'm up at 3:45am.
2) My apartment has no internet, so I'm typing as I eat my Panera sandwich.

The last three weeks have been exactly as it says in the title...kinda boring. Prior to this rotation I thought I would find surgery exciting, but as a whole I have been pretty disappointed. Surgery for a PA is a totally different experience than for a doctor. We make no final decisions and our voice is never the one the scrub tech is listening for most. Autonomy is one of the reasons I chose becoming a PA over a nurse or medical tech in the first place.

Clinic is even worse. 50% of my patients are here for one kind of bariatric surgery or another. Either that or they are follow-ups without complications, because any complications are usually dealt with in the hospital. All have been screened by primary providers for any serious conditions and almost none have findings on physical exam. Remember, this isn't an ER, it's scheduled patients. Gallstones don't schedule appointments. Not a single surgeon here carries a stethescope, only the residents. There are some minor procedures, and I try like mad to get in on those, but it's like feeding a starving man a saltine without water.


The only redeeming thing about this rotation is my Chief Resident and rounding. This is where I learn the most, get pimped the most yes, but it's all in the nature of teaching. Patients are sick, they are complicated, and they actually have findings on physical exam. Sure I have to get up early to do it and stay late to finish at the end of the day, but I think the trade is fair.

Just 3 more weeks....counting down...

Sucking the Government Teat....Or Just Sucking???

My time in Forks was up, so I hopped in the car and drove to my next Herculean Labor-surgery at an Army Medical Center. With it's many bureaucratic heads, very ugly visage, and the ability to leave a PA student feeling eviscerated, I figured this must be the Cerberus of my labors. In fact, I kinda wish I could just show up with a club and start bashing heads around. Working here is like swimming in chocolate pudding: very difficult, very slow, and at the end of the day you kinda look like shit.
Now don't get me wrong, there are many good things. So far I have performed some really cool minor surgeries. Several lipomas, cysts, and inflamed lymph nodes have fallen to my glorious Scalpel of Sterility (not the reproductive kind), and I have gotten to assist with some pretty cool stuff in the OR. However, the go-to phrase around here seems to be, "I don't deal with that". Problem: PA student needs computer access so he can review charts and see patients. Solution: A one week wait while the request is run through the "proper channels". Never mind that his Chief Resident is breathing down his neck to help carry the load, never mind that he is PAYING for this rotation. I have visited 6 different offices to try and expedite the process, only to hear "I don't deal with that" from at least 4 of them (the 5th was "out sick, sorry but nobody else here can help you", and the 6th was my preceptor. He actually called to yell at someone...to no avail).
Another interesting thing is defining "medical necessity". 46 year old male patient walks in with irregular, somewhat mobile, 2cm hardened mass in supraclavicular notch. History of smoking and family history of lung cancer. No other nodal involvement and no other indications for cancer, but the thing bothers him when he wears his packs. He wants it removed before he deploys next month, but somehow the doctor talks him into "watching and waiting" while he is abroad. I walked out of the room with my jaw on the floor. This man has some great risk factors, and the node is irritating him in the first place-why not just excise it and send it to pathology for shits and giggles? No follow up scheduled, no chest X-Ray, nada. After following this doc for awhile I realize this is a trend in his practice, so it must have worked out for him in the past. On the other hand, I have never heard of so many bariatric surgeries. Lap Bands, Gastric Bypasses, Roux En Y procedures...they do them morning and night, every day. it's damn near as common as gallbladder surgery. Whole different definition of medical necessity. Between rounding, clinic, surgery, pimping, running between computer offices like Forrest Gump after a blonde hippie, and more rounding; I am beginning to feel less like Hercules, and more like..dog food.




Anyway, dead tired after a 14 hour day and going to sleep...at 7pm...shit.

Why I Like Backyard Volleyball

I think if you asked anyone, they would say they like the outdoors. Camping, hiking, rockclimbing; they're all pleasant pursuits for both their exercise and aesthetic value. Individuals like to test their mettle with mountain climbing, and that's where today's encounter takes us:

**Today's story told with permission from the patients, all identifiers have been changed to protect the extremely lucky**

Doing the walk-in schedule for the Urgent Care here in Forks. I am getting comfortable now seeing patients on my own, getting histories and performing physical exams. Often I will write my assesment and plan down on a sticky note for my preceptor to read as he follows behind me. This actually works pretty well, and not only makes me evaluate on my own, but does alot of the grunt work for the preceptor (he usually sees a patient on his own, then pops in to talk to mine really quick at the end). Yesterday was like any other except when I saw two charts in the door of room 3. Occasionally we see bros and sisters, or mom and new babies, but when I read the chief complaints of both they said, "Fell off cliff".

Turns out these two (Erma and Norbert), were participating in a final project for their master's of Wilderness Instruction and Survival for a university back east. Together with 12 others (4 instructors and 10 students), they had been in Olympic National Forest for the past 23 days. They were high above the snow line, outfitted with crampons, ice axes, helmets, and other various implements of high mountain recreation, descending along a path in the ice after their final ascent of the peak. Erma and Norbert were roped together, when one of them stepped off the trail, slipped, and pulled the other onto an ice slide. The slide ended at a steep cliff 200 yards down the slope. As they continued to slide and pick up speed the entire way, their axes could not penetrate the hard ice deep enough to gain purchase. Over the edge they flew. One hundred and eighty feet they fell, slamming into the cliff face every 20-30 feet or so (this probably saved their lives). Right before a 50-75 foot section of drop off (with no cliff face to hit), Erma's ice axe lodged between two boulders. With her elbow and wrist taking the brunt of the weight, Norbert climbed above her and tied into the cliff face. Slowly he tied Erma in, they climbed back up the face until reaching a flatter section where the rest of their party had run down to. Their party checked them over for obvious injury, shock, concussion, etc. They then walked while the adrenaline was still holding back pain until they were over halfway out of the park. The next day, loaded with ibuprofen and limping, they walked the rest of the way out. They woke up, drove to the hospital parking lot, and sat there bruised and broken, staring at both the "ER Entrance" sign and the "Urgent Care" sign on the other side. They chose Urgent Care because it had been 2 days, (does that qualify Chip?).


They both looked like a cross between Sylvester Stallone at the end of Rocky I (where he looks like bruised shit), and a scratching post at Seigfreid and Roy's house. Norbert was missing 4x4 inch patches over his left knee and shoulder, right ribs, and right cheek. X-rays showed a separated shoulder (Level 2), and a right patellar fracture. Painful, but he'll live. Erma was far worse off. She was wearing short sleeves when they fell, and they had gone through several small trees. Her right wrist and elbow were severly swollen from the jerk when they stopped, with almost no range of motion. Her entire (and I mean ENTIRE!) ass was bright purple, and she was almost unable to sit anywhere. Her back was missing about half it's epidermal layer, and the inside of her left thigh looked Tye-Dyed. However, the most serious thing was her feet. While her boots had protected them during the fall, the hike out have given her three severe blisters. After 3 days without changing her socks/shoes, they had become infected and inflamed, with angry red swelling reaching above her ankle. It took my preceptor and I almost an hour to diagram the two of them, then it was off to the hospital for 2 days of IV Vancomycin for Erma. With a little Percocet, Gatorade, and Cheese Fries they were both looking better the next day and were ready to fly back East as of this post.

Moral of the story: If you want to pass the final of your "Wilderness Instruction and Survival" class, a good way to get an "A" is to go flying off a 180 foot cliff and live (not sure how that measures the Instruction part of the class. As for me, no thank you. I will BBQ some steaks, drink some iced tea, and get together with family and friends for backyard volleyball. That way, if I want to test my mettle, I will just raise the net a couple inches...besides, the views can be just as aesthetically pleasing.


-JW

"Whaaatcha dooo-in"......"learnin' stuff."

As a PA student in my first rotation, I am learning so many new things each day. Sometimes it's really hard to keep up. Check out these 3 gems I discovered lately:

1)Addicts will do anything for drugs, ANYTHING
60yo gentleman, w/ R shoulder pain, injured on job 5-10 years ago but has a "flare up". Other than that he's been great for 3 years. He states "only thing that's ever helped is oxycodone". He tried "Vico-Dans" and it wasn't powerful enough. I look over the chart and "shoulder pain" is on almost every visit, and he's received lots of oxycodone. My gut says "malingerer", but I withhold judgement. After all, it's been 3 years w/o a visit.
He states no recent trauma, "just a flare up". I notice in the chart he was actually fired from the practice 3 years ago for repeated +tox-screens and bad pill counts, but somehow got an appointment again. I decided that I was gonna do a FULL physical exam. If he was a malingerer, at least I would get to practice all my exams. If he really did have some pathology, hopefully I would find it (besides, he's 60 and probably hasn't seen a doctor in 3 years). Either way we both were gonna get something out of this. I approach it by telling him it's been awhile, and we should check on everything; a full tune up rather than just an oil change. He likes this idea and goes with it.

I do the usual as well as really detailed stuff. Tactile fremitus, fundoscopy, clonus, visual fields, spleen palpation and percussion, diaphragmatic excursion, stereognosis, patellar ballotment, etc. (by the way, everything is setting off his shoulder pain; palpation, A&PROM, axilla palp, +Neer, rotator strain/sprain, decr. strength, and biceps groove. He even grimaces when I press on the sternoclavicular joint, saying it hurts in his shoulder. Basically, he's somehow positive for every shoulder injury discoverable. Up to now he's been compliant. Hell, better than compliant, he's been patient and willing to prove his legitimacy. When I ask him to drop his drawers he finally asks what this has to do with his shoulder, and I can tell he's getting impatient. "Sir, you are 60yo, rectal and prostate checks are pretty standard for a man your age. I have just this last thing and then we can talk about options for your shoulder pain." Bingo, pants go down and he's whistling.

Except for some vision problems and the shoulder thing, it's all negative. I go to my preceptor, who sees the name and refuses to dispense narcotics. When he finds out all he's getting is Naprosyn 500mg and instructions for stretching, he goes ape shit. Hollering that we wasted his time for this "weak smurf shit", he doesn't seem to notice his suddenly increased ROM as he waves his arms to make his point (I claim this cured him). Leaves, promising never to return.


2)ALWAYS get a complete history.
63 year old woman presents complaining of fall from short stool onto kitchen floor. Really twisted her ankle, and oh yeah, hit her ribs on the counter on the way down. She seems kinda short of breath so a more rigorous physical is warranted after my "complete" history:

GEN: WDWN, A&Ox3
Skin:Pink, warm, intact
HEENT: Normocephalic/atraumatic, PERRLA, EOM's intact, normal conjunctiva, TM's normal, neck is soft/supple w/o JVD or lymphadenopathy, mouth/throat normal.
CV: RRR, w/o MRG, pulses intact, good cap refill
PULM: clear to ausultation...on one side? No sounds on the other at all? What the... OOOOOOOHHH SHHIIIIIIIITT!!!!

I stop the physical, excuse myself and run to the nurses station. Gallantly I shout that we need to have the ER (across the parking lot) send over a gurney immediately for a possible pneumothorax. Beaming like the hero from a comic book cover, with chin up and hands on my Stethescope of Salvation, I go to inform the preceptor. The nurse reaches across the desk and grabs my coat, stopping me short.

"*JW*, are you talking about *Gertrude*? Cause she's missing a lung on the right side, has for years cuz' of lung cancer. You wouldn't start yelling for a gurney without asking her if something like that was normal, would you?" THANK GOD for nurses.
(**=Names changed to something ridiculous to protect the moronic and innocent)


3) Everyone knowing everyone's business isn't always bad. HIPAA be damned!
See #'s 1&2

Excuse Me? You do what?

A couple days ago I saw a patient in for a 6 month f/u on diabetes and vision. Seems he is a veteran who lost most of his sight during the end of the Vietnam War due to injury. He is entirely blind in his left eye, and his right eye while having major acuity problems, is perpetually turned inward because his extra-ocular muscle were severed by trauma and unrepairable. We get to talking and I am asking about his life, family, and job when he blindsides me with this: He is the town barber! The man has almost no vision, has to turn his head way to the right to be able to see his hands when he's working, but he has been cutting the men's hair in Forks for the last 25 years. Needless to say I was a little stunned, and mentioned it to the doctor I was working with. His response was, "Yeah, me and my boys all get our haircuts there, he does a really good job. You should have him cut yours." What did I say? "Okay"

(Before you start to think I was just asking for trouble let me explain something to you about me and my hair. We have a hate/hate relationship. In fact, my body hates my hair so much it's starting to banish it from my head starting near my brow-line (although advances have been made into the enemy territory at the crown as well). Now it just grows thick on the sides, into a kinda football shaped orb. Think Jack Black with a head like Stewie Griffin from Family Guy (probably not gonna get to many job offers with a melon like that). So when someone mentions cutting my hair, even if that guy cuts hair like Gallagher makes fruit salad, I am gonna do it)

Today my preceptor was off, so I figured, "Why not today?". I show up at the Barber Shoppe around noon, and see a sign posted on the door saying "Go to Bait Shop" Turns out that all the shops along this street are Mom&Pop stores and they don't get much business, so they spend most of their time in the center store which is a fishing tackle repair shop. I poke my head in when I hear the noise and the barber instantly sees me since he's looking that way (what are the chances?). Once in the shop, he sits me down and starts cutting my hair, quite speedily too. Sure enough, the guy is BOMB-DIGGITY! As the noon rush hits, a line forms that goes out the door. Just local guys needing their hair cut and wanting to get it done over lunch. I think, "There's no way he is gonna get all of us finished before they need to get back", but 5 minutes later he boots me out the door. One look in the mirror and I knew how this guy had survived 25years as a blind barber. He was the Jesus of barbers, healing bad haircuts for the masses, raising the combover from the dead. For once both myself and my hair called a cease-fire. The kicker: it only cost me 6 bucks! I can get three haircuts there for the cost of one Supercuts trim. Hell, it's almost cost efficient for me to drive up from Tacoma to get my hair cut in Forks. I thanked him, told him I would be back before my rotation was over and that I would try and bring more hair if he tried to bring me a lower fasting glucose.

Grow 'Em Big In These Here Parts

Saw a couple cases of head lice Thursday. The first one, it was alright. She had a couple of nits behind her ear and had been scratching for a couple of days. Rx for Ovide, tell her to wash her sheets or get outta the house for a couple of days, go camping or something. Nothing major....boom, Roasted!

The second.....I keep replaying the encounter in my head. Just imagine, big pregnant woman, with head lice the size of cockroaches. These critters weren't surviving on her scalp, they were evolving there. I swear to God I saw one using a bow and arrow, while another was jumping around a bonfire yelling, "LOOK WHAT I HAVE CREATED!" In all honesty I didn't even have to look for them, the lice were crawling everywhere. Turns out she has had this infestation (as have all her children and husband) for the past 18 months or so. She has been prescribed everything under the sun, but always insists it burns too much and stops using the treatment after an hour or two. I should have informed her that it wasn't the chemicals burning her that hurt, it was the evolving lice beginning to use plows on her scalp. We did the usual stuff, warning her about the risks to the baby, and that she can't use the lotions on the baby for almost two years. Talked some more about the importance of combing them out of everyones hair, etc, etc, blah, blah. The idea of cutting her hair off was brought up (did I mention she was Native American?), not gonna happen. She left without any treatment for it whatsoever and we quarantined the room till the Haz-Mat Team (janitors) could come with flamethrowers and declare the place clear.

What will probably happen: She'll get to Seattle to deliver the baby (she is high risk due to previous surgery complications), and they'll just hold her down and treat her before the C-Section or right after it.

How do you help someone who obviously (for the past 18 months) does not want your help? Why do they even come in anymore, apparently she wasn't getting the answer she wanted (this was the 6th visit for lice in the 18 months). But after the 2nd or 3rd visit, we ran out of solutions to give her. Goosefraabaah. Calm yourself JW. Goosefraabaah.

Forks, Dumpy Vampires, and Tourists

Been here in Forks, WA for two weeks now, and finally getting the hang of things around here. For the most part I like the town. First getting here, all anyone ever talks about is how much it rains (the amount of rain they get, different kinds if rain they get, the color of the rain, recipes for cooking rain, songs about rain, etc, ad nauseum). However, in the past two weeks we have had beautiful weather. It has rained a little, but you soon realize that's why everything here is so wonderfully green as well, and it's worth the trade. Yesterday I drove to Port Angeles (residents just call it PA). I parked in a lot right off of the ocean, but when I looked back inland, the snow covered mountain peaks were so close it felt as though you could just reach out and touch them. I sat there for a couple of minutes and just appreciated the thought of how close to the ocean these awesome peaks were.



For those of you not "in the know", Forks is also famous right now. It happens to be the setting for the profitable book-to-movie, "Twilight" series written by Stephanie Meyer. In the book, a young Bella Swan moves to Forks, where a family of vampires named Cullen and Native American werewolves inhabit the surrounding areas. The movie was released last year and since then the town has been a madhouse for tourists that come to see "Bella's Birthplace". Unfortunately for the tourists, Forks has absolutely nothing to do with the books...NOTHING. Apparently the author simply did a websearch for the city in America with the greatest rainfall/year and the name came up. Before writing the novel she had never lived here, never visited, nada, nothing. Even the movie has nothing to do with the city. There is one scene filmed in Forks that shows the "Welcome to Forks" sign, everything else was done in either Vancouver, WA or the Portland area.

However, driving through the city, you would never think that. The sign as you enter town now says, "Welcome to Forks-Home of Twilight!", all of the hotels have signs saying, "Vacancy, Vampires welcome!", and the local hospital has a parking space that says, "Reserved for Dr. Cullen" (I think the janitor guy actually parks there). Every business (and I mean EVERY), has some mention of the movie, from the Bella Burger at "Sully's Burger Joint", to the multiple movie posters in the windows of the local chinese restaurant. A special "Twilight Store" offers tours of the town, showing you such wonders as the high school (that wasn't even in the movie) that Bella would have attended (had she been a real person instead of fiction). My first day I went to the town's Visitor's Center (only place with WiFi) and sat outside at a table. A short black bus, painted with little diamond sparkles pulled to a stop just shy of the door. Out came (and I shit you not) about 6 middle aged, dumpy women, all holding copies of the book. The last to get off was wearing a black cape and had deep red lipstick painted on as well. I could just begin to imagine the fake teeth when she opened her mouth and....BOOYAH-fake teeth! This was the tour, and it runs twice daily, and people PAY FOR IT! I noticed the tour crowded around an older model red Ford pickup with a Washington license plate that said BELLA on it. It looked quite a bit like the truck from the movie (except the one in the movie is a Chevy), and there were about 20 people crowded around it taking pictures and pointing. When I went into the center to ask about other Wifi sites in town, I mentioned the discrepancy to the information chick. She said,

"Yeah, that trucks been sitting there for awhile, it was originally part of the logging exhibit. But so many people kept asking if it was 'Bella's Truck' I finally just went outside and put that license plate on it. Now we sell pictures of it to the tourists"

As I have mentioned before, I don't blame the people of Forks for all this. They need the boost in the local economy, and have to take advantage of what they can get, wherever it may come from. But the fact that busloads of tourists are here to take pictures of some random diner (because they thought it was from the movie), instead of taking a hike in the only temperate rainforest in the Northern Hemisphere just seems....fucking ridiculous.

Housing Search Part 2-"The Midnight Visitor"

So if you scroll down, you will see my previous story about a wonderful cabin in a swamp, *Just Right* toilet paper, and baby elephants. Here is where the saga continues.

After leaving Chigger's place, I headed to what I thought was my only other option for housing in Forks. An older widowed woman was renting out a double wide trailer about 20 minutes outside of town, but wanted almost $500/month for it. I decided after the clear bathroom fiasco that maybe this was a gift horse. When I arrived at her house (now with less than 36 hours till rotations started), I saw a small petting zoo. Chickens, goats, ducks, peacocks, a couple dogs, and a llama called this place home. Then I saw her...

She looked like Prof. Trelawney(?) from Harry Potter. Coke-bottle glasses with 4 inch diameter lenses, I knew why she was living in this cloudy rainforest. If those glasses ever caught and focused the sun, her head would burst like JiffyPop. She approached me like Noah, or maybe more like Ace Ventura when he calls his animals. We made small talk and walked to the trailer in question. I didn't see any fences other than the large outer one, and wondered if the yard was all one big cage. I also wondered why I wasn't stepping in more bird/goat/dog/llama shit. I soon found out why. Apparently, the front porch of the trailer was the designated litterbox for the farm. The railings around it were painted white...not with real paint unfortunately. Upon entering the trailer, I I wondered whether the previous owner had dogs, or if the dogs I had seen outside were the previous renters. My acute sense of smell was interrupted by a shrill, load cackle directly behind me. It was a male peacock. I asked what I thought was a very important question:
"Are they like chickens, they wake up early in the morning to crow or anything?"

"Oh no! They make that noise all day an night!" she replied with a self satisfied smile. I think she actually liked that about them.

I decided at that point that maybe this wasn't the place for me either. Perhaps that syringe floor apartment was still available? Probably a good decision too. From what I heard at the clinic, the last renters (male) complained that occasionally Miss Glasses would tip back a little too much Vicodin and come over for a visit...of the conjugal variety. It was kinda like that Garth Brooks song "That Summer", lonely widow woman and all that stuff. Except in the song I kinda felt the lady was good looking, y'know a cougar. Not a retired hippie wearing a moomoo literally covered in chickenshit. I guess when you think about it, the lady in the song coulda looked like that too, she was trying to run a farm. **My opinion of Garth Brooks just took a massive blow**

I declined that rental offer as well. Fortunately, at the last minute, my preceptor called and said he had found some housing I could use that was in town and really cheap. Crap, gotta sign off.

The "See-Through" Cabin

So.....yeah, it's been awhile. I been busy, bite me.

Just settling into my clinical year here in Forks, WA. Doing the rural thing and quite frankly, loving it. The town is **TWILIGHT** crazy, but then again this community needs the stimulus. A once famous logging town on the Olympic Peninsula, Forks' economy froze in the 70's (not sure if that's 1970's or 1870's). Overall it's really nice, walking down the street and recognizing all the patients that you saw the day before. Educating them for 20 minutes about the dangers of hyperglycemia and insulin resistance, then having them spot you at the only grocery store in town buying a 12-pack of pepsi and Haagen-Daz. Right now I am living with a nurse practioner in a "Mother-in-Law" apartment above her garage, but it wasn't always this way. Come along and enjoy the saga of how I fell into cowshit and came out smelling like a rose....

The 3 weeks preceding clinical year I was trying like hell to get housing in this small town of 3,000. Rental property is limited, and since the population hasn't changed since FDR got polio, it didn't look like anything new was gonna pop up. I finally got a return call from a gentleman by the lovely name of "Chigger" who was renting out a "Wonderfully rustic cabin in the Olympic National Forest" for the pittance of $350/month. He gave me instructions to his cabin and told me to go ahead and check it out, even though he would not be there (they really trust each other out here, it's cool). I drove out in the early morning, arriving at a very secluded log cabin, surrounded by meadows and a creek. All of this was enclosed by the Olympic Mountains on all sides. The added bonus was that it had phone service/Wi-fi/indoor plumbing/ and was only a 20 minute drive to town. I thought, "WOW! What a great deal, I can sit out on the porch surrounded by this beauty and write my SOAP notes, all the while being available for ER calls!"

The next morning I called Chigger, and told him I really liked the cabin. He told me to come out and meet him to talk about the details of the lease. When I got to his house, I told him I loved the cabin, with the cedar-shake roof, and rough cut barn wood in the bathrooms. His response was, "Bathroom-S?" Apparently, I had gotten the directions wrong and had taken a right instead of a left somewhere. I had inspected, rifled through, and used the bathroom in someone else's vacation cabin for over an hour like an overweight, middle-aged Goldilocks! Oh well, at least the toilet paper was *JUST RIGHT*
Then Chigger took me to the REAL cabin he had built. It was about 60 feet behind his new house.....in a swamp. It was just bigger than a postage stamp, and had been cobbled together from pastel boards from what could only be the Partridge Family's concert set. The bedroom fit a size double bed..and that's it. You had to jump from the foot up to the head because the walls on each side touched the bed. Another bonus: I was only allowed 2 megawatts of power each day. That's about enough to light a 100 watt bulb for 24 hours. I guess his main power source was a hydroelectric wheel in a nearby creek. Cool, but kinda a pain in the ass for a guy who spends all night on his computer and runs a fan in December. Also, no phone service, spotty Wi-Fi from Chigger's house, and all this for $350/month.
But the best part was the bathroom! To save on heating in the winter, Chigger had decided to build the ceiling AND ALL THE WALLS out of clear plastic used in greenhouses. Yep, not only would my neighbors get to see a daylight moon every morning, but the local ecosystem and wildlife would forever be influenced by a shy baby elephant in their midst.
As I left, I told Chigger I would have to think about it, knowing that unless my only other option was a crackhouse with a syringe laden floor, this baby elephant was taking his trunk on safari.

ER just called. The saga will continue. Keep on Scrubbin'!

Like Tupac says, " I don't see no changes...."

Countdown to clinical year is just under 5 weeks. Looking back on the past year, it has flown by. I just keep wondering if I have learned enough, experienced enough, remembered enough, and matured enough to do this. This year has had a subconcious change on me. When you sit in class with the same people, hang out with the same people, literally eat/piss/bleed with the same people; you lose the baseline for who you were a year ago. Everyone is going through the same changes with you, and sometimes it is hard to see how you have grown. Maybe the individuals who are married w/ or w/o children don't know what I am talking about. They go home every day to loved ones who see the changes.

I am a class clown, always have been and always will be. I see myself much as Turk and JD see themselves on Scrubs. I like to joke or lighten the mood, but I know that when the situation calls for it, I adapt and put on my "Clinic-Face". It's kinda like that Sylvester Stallone movie, "Over The Top". Sly explains that turning his hat around "turns his attitude around". Dialogue...so....deep....can't resist...bad...80's...movie. (Never underestimate a guy willing to star in a movie named, "Stop, Or My Mom Will Shoot.)

I figured I had learned a bit of medical information and technique, but I didn't feel the changes at my core. However, a couple of weeks ago (during Spring Break), I suddenly realized how much this year had affected me. My baseline had shifted. I was no longer surrounded by my classroom peers, and it was apparent how much I had learned. More importantly, my "Clinic-Face" kept bobbing to the surface more and more. It took awhile to realize that "Clinic-Face" was actually "Responsible-Adult-Face" in disguise.

I think incoming PA students should be aware of this. They are gonna sit in class day after day, listening to lectures, thinking they are wasting time. To those students: You aren't...entirely. I am not gonna say you won't be bored, or that you don't deserve to be pissed off when you feel the carpet is being pulled out from beneath you. However, without knowing it, you are changing and you are learning. Perhaps that itself might keep me going for another 5 weeks!

JW