So I’ve been back from Tennessee for just a few days, and like last year, I miss it and everyone terribly.

My last week was as good as all the others, save for the one crotchety patient (my last patient!) who didn’t want a student.  The staff gave me a really lovely sendoff—Kimberly, my friend from the front desk, bought me roses, which rode all the way back to Boston buckled into my front seat.  Mary and some of the gals in the back of the office got me a basket full of stuff for camp—bug spray, sun block, etc.  It was a really warm goodbye, with lots of hugs, a few tears, and countless see-you-next-years and y’all-come-back-nows.

After I left the clinic Thursday evening, I drove “up the valley” into Kentucky (about 40 miles north of the clinic) and up to the Pinnacle, an overlook that gives a near 360 view of Kentucky, Tennessee, and Virginia.  It was an incredible view (see pics), and a really good way to say goodbye to Tennessee.

The next morning, I went for one final jog through my neighborhood, said Moo to the cows and ran with a few stray dogs trying to bite my ankles, and then got on my way back north.

The first day I drove about 8½ hours from my house up to D.C., then next day 3 hours up to Cherry Hill, NJ where I saw a bunch of relatives (Hi Aunt Marian!).  On Sunday morning I drove another 7 hours and finally home to Peabody, MA.  When I hit terrible New York City traffic, I felt my blood pressure rise, and I knew I was back in the north

I moved into a camp in Amesbury, MA on Monday, where I will be working for the summer as the camp nurse.  The campers are 7-17 year old Jewish boys; OY! And in the infirmary, I dont get cell service--it is just like Tennessee!

Unless life interferes, I do plan to go back to work as an NP next year.  I expect to be fully licensed around the end of next summer, so I’d probably move down around August.  As June, my favorite triage nurse said, I’m not leaving; I’m just going on a 15-month vacation.

I’m really excited to go back next year—I can’t wait so see everyone again. And I am excited for work; like I said before, I really looked forward to going to work every day.  That is priceless.  As my step-dad says, there is nothing better than doing what you love, and get paid for it.

I’ve also been having fun trying to find housing online in that area—though since most people in Appalachia don’t actually have computers, online real estate is pretty limited.  I probably will rent for a while, but I’d consider buying a home.  Since property is so cheap, a mortgage payment would be far less than what I pay in rent now.  On a few of the houses I looked at online, my mortgage payments would be less than $200/month (one was $78/month, but I think it was in a cemetery).  However, I know that there are tons of extra costs when you actually own the home—especially older homes—so it’s definitely something to think about. 

On a weird and exciting note, due to the difficult economics of being a solo pediatrician in a economically depressed town. my step-father Walter, who is a pediatrician in Lynn, MA, decided to close his practice. He decided he wanted to join into an existing practice, so he had been looking for jobs in the Boston area.  Unfortunately, or fortunately (depending how you look at it), he wasn’t able to find one that was a good fit for him.  So he branched out, interviewing all over, including Denver and Virginia.  Finally he found a practice that looks like a great fit, and they offered him the job.  He signed his contract yesterday.  The kicker…the job is in Nashville, TENNESSEE!  My mom and step-dad are moving to Tennessee before I am!  They are moving in September and he starts work in October.  When they came down to Nashville a few weeks ago, he was interviewing and my mom and I were looking at homes for them to buy.  How wacky and wonderful! It will be very strange when I go to their house, I will no longer be going home, I will be visiting them.  But is also really exciting—and such a relief that I will only a three-hour drive from them next year, instead of a 16 hour drive or several-hour expensive plane ride (from Knoxville to Boston).  I will have to figure something out so I can visit my step-sis and friends who stay in New England. That was something that bothered me about moving to the south—being so far from my mom, but no worries.  It is also a reasonably-priced plane ride to points west and mid-west, where my brothers and dad live. So wouldn’t it be ironic if life throws me a curveball, and I end up staying in Boston?

So I have a fun summer ahead of me at the camp, and then just one more year in school to go.  I cannot believe how fast life is moving, but I am determined to enjoy the ride.

So last week I sat down with Jada, the head of the health center.  I told her that I was definitely interested in coming down here to work at REACHS when I finish school next year, and that I wanted to find out what the application process would be.  She replied, “Well, we were hoping you would come, so you just have to fill out the paperwork.” So I have officially unofficially lined up a job for after graduation! When I asked about pay and benefits, she grimaced and said the pay wasn’t much.  I’d assumed this would be the case since it is a federally declared undeserved community, and they are constantly writing grants so that then can afford supplies, medications (i.e. vaccines), educational programs for their staff, and just the money to pay the bills for a practice in an economically depressed region. But when she told me the pay scale, it was significantly better than what I had expected (and was willing to settle for), and not drastically below the national average for new NPs.  And due to its underserved status, I can apply for tuition repayment from the government, and possibly get some or all of my school loans paid off. Not to shabby, eh?   In order to get the tuition repayment, I must commit to a minimum of two years of service in an undeserved community—sounds good to me. 

Alayna, my friend from school who came down with me to work with Sheila, flew home on Friday—I miss her.  It is so strange coming home to an empty house.  When you share a home and a car with someone, you pretty much come and go together at the same time all the time—I came home tonight and realized I have not spent an evening without her since exactly one month ago. The house seems so much bigger now.

I went back to Nashville this past weekend to see my mom and step-dad who came in town for the weekend (another story for another time).  Saturday night, we went to the Grand Ole Opry—yes I have been three times and I’m not ashamed—I know many Tennesseans who have never been once.  We spent a lot of time driving around the city and I was struck by the overwhelming disparity of wealth that exists—some within Nashville, but mostly from Nashville compared to eastern Tennessee where I live.  We saw multi-million dollar mansions (Nicole Kidman and Keith Urban live in one) that you would expect in L.A.; about 250 miles to the east, there are people who live in there cars or do not have telephones or running water—it is a remarkable difference.  We actually got to go into one of the mansions because my step-dad knows the owner of one.  Their dog has his own marble-floored room.  People like nice things—I get that.  But there is so much excess and overindulgence, and I find it pretty off-putting. It struck me that when I think of Tennessee, I think about where I live in the eastern part. When I think of Nashville, I don’t even think of is as part of Tennessee.  It is its own country.

This is my last week here.  I decided to take Monday off so that I could spend a little time exploring Knoxville.  Unfortunately the city isn’t too hopping on a Monday afternoon.  I checked out the McClung Museum at the University of Tennessee which houses a collection of Egyptian artifacts, an exhibit on the ancient history of Tennessee (i.e. the fossils from a few thousand years ago and an exhibit on the American Indians (is that the current P.C. term for it?) who once lived here, an exhibit about some civil war general, one on the (??) bronze tools and artifacts of the native Asian plains people, and an exhibit on Tennessee clams and oysters, and the booming Tennessee freshwater pearl industry, and some other stuff.  Overall the museum was very disjointed and I was not super impressed, but the pearl thing was pretty cool, and it had a few other neat things.  There is an art museum of Knoxville but unfortunately that is closed on Mondays, along with a bunch of art galleries and restaurants.  Not quite sure why, but that’s the way it is.  So I walked around the city a bit, and also checked out a bead store I’d heard about and a used book store (both recommended to me) that makes the Strand in NYC look like a kiosk. So Knoxville is certainly not the Mecca of culture that I would love to live nearby, but it certainly has its charms (just not on Mondays). 

And up here in the Appalachian (pronounced apple-latch-in) mountains, I am content.  Alayna and I went kayaking on Norris Lake the other morning before she left, and I felt completely at ease.  I could live on this lake (and I hope that I will).  And Sunday night on my way home from Nashville, I drove past Cove Lake, a park about five minutes from my house.  I was passing by in the late evening, during that breathtakingly serene evolution of dusk into darkness.  I pulled over to watch the sunlight fade mauve behind the Appalachian Mountains and I felt so lucky to catch this moment of beauty and feel like I was home.

So I will be working just Tuesday, Wednesday and Thursday this week, then I leave on Friday. I will have completed 176 clinical hours this summer. Only 112 of them were required, but I’m having too much fun to leave just yet. 
<img src="http://picasaweb.google.com/shana.kaplan/Tennessee2008/photo#5210738775187683970" alt="Cove lake" />

This week has been pretty packed.  I had a few really interesting cases at the clinic.  Here are the semi-paraphrased versions of my notes for two that I thought were most impressive (and exciting).  I took out some of the medical lingo—but left most of it.  If you don’t want all the details, I sum it up and add a little bonus info at the end of each note:

#1 Chief complaint:  Left leg swelling

Subjective: 66 y/o M c/o left leg swelling, bruising, pain, redness, and warmth X2 weeks.  Had a minor motorcycle wreck 1 month ago and had a large abrasion on L knee.  Was not seen for it.  Wound was healing well w/minimal pain and no swelling until 2 weeks ago when it became very swollen and tender.  The rest of the leg swelled as well from the mid-calf down to the toes.  Says leg became very bruised and looked black.  Says it hurts to push at the abrasion site, and his calf feels sore and very tight.  Denies chest pain or shortness of breath. Patient says he does not want to go to the hospital.

Current Health Status: Depression, GERD, Coronary artery disease, myocardial infarction (heart attack) 2006, Sleep apena,  Chronic obstructive pulmonary disease,  ADHD, high cholesterol

Meds: Prozac 20, Nadolol 40 Prilosec 20 Plavix 25 Imdur 20 Baby ASA Lipitor 40

Allergies: none

Health Habits: non-smoker, quit 16 years ago.  No alcohol. 1 cup coffee/day

Family history: no known clotting diseases in the family. +history of CAD and hyperlipidemia

Objective

Heart rate 88,  Blood Pressure 156/86, Temp 98.7, O2 Sat 98%

No acute distress.  Heart regular rate and rhythm, no murmurs.  Lung sounds clear bilaterally, no adventitious sounds.  R leg normal.  L leg very swollen and red from the mid-thigh down to toes. Diffuse non-blanching bruises mostly medial to the knee.  Significant edema around patella.  Abrasion site seems to be healing well. No discharge or bleeding.  Point tenderness over site, but knee otherwise non-tender.  Normal range of motion of knee.  Left calf 49.5 cms, Right calf 42.5cms.  Left foot swollen and dusky, non-tender. Good sensation and pulses bilaterally. Negative homans sign.

CBC normal. WBC 9.1

Assessment Deep vein thrombosis (blood clot) vs deep cellulitis

Plan: consulted with Dr. Fernandez

DX: refer for stat venous and soft tissue Dopplers at St. Mary’s.  Sent off PT/PTT.

RX: Keflex 500mg QID X10

ED Discussed importance of sending him to the hospital and that he may need to be admitted.  Talked about potential blood clot vs. cellulitis.

FU: will follow up when we get the Doppler report.

So basically, this guy likely had a blood clot deep in his left leg that was blocking the bloodflow back to the heart—which causes swelling.  If the blood clot breaks off and travels to his heart, lungs, or brain, he could die instantly.  We told him about this risk and referred him right over to the hospital for an ultrasound (Doppler) that would indicate if there was a clot or not.  If it wasn’t a clot, the other potential diagnosis is a deep infection (cellulitis).  However, his WBC—white blood count—was normal and suggested no infection.  We gave him a prescription for antibiotics just in case. We got a call from his wife the following day saying he didn’t got to the hospital and was refusing to go at all.  The nurse reiterated that if this was a clot, he could die if untreated.  His wife said he was still refusing to go.  I will hopefully find out what happened on Monday. 

-

#2 chief complaint: chest pressure

Subjective 50 y/o M c/o chest pressure rated 4 out of 10 for the past few hours.  Describes pain as slight pressure in the R upper chest that does not radiate.  Does not seem to be associated with exercise or with food. Has had this pressure intermittently for the past month and a half with increasing frequency and duration.  Says he had similar pressure for about a year that seemed to be associated with exertion and as relieved with rest. He also noticed increasing frequency of shortness of breath and dyspnea on exertion (getting out of breath with activity).  Denies indigestion, nausea, vomiting, headache, changes in bowel habits, or rectal bleeding. Denies lower extremity swelling but noticed some spider veins recently on his ankles.  He also noticed a cough but it comes shortly after taking his Lisinopril.  He says he can tolerate the cough. Says his wife checks his blood pressure @ home and it is usually in the 120s-130s/80s-90s.

Current Health Status: hypertension, well controlled

Meds Lisinopril 20 mg ½ tab QD, Baby ASA, Fish oil 1000mg

Allergies: none

Health Habits: ex-smoker, quit 25 years ago.

Family history: +for hypertension (mom and dad), negative for high cholesterol, heart attack, stroke, diabetes.  Dad diagnosed with colon cancer when he was in his 70s

Objective

Well appearing, pleasant affect. No acute distress.  Lung sounds clear, no adventitious or diminished breath sounds.  No labored breathing. Heart regular, with no murmurs. Normal S1 and S2. No tenderness on palpation of chest. Abdomen soft non-tender. No  enlarged organs

Chest x-ray initial read unclear.  Poor inflation on left vs left diaphragm distension. slightly enlarged cardiac silhouette. Increased perihilar markings. No obvious lesions.

EKG showed sinus rhythm with lateral ST-T changes that may be d/t myocardial ischemia (oxygen depletion in the heart).

Gave patient 1 tab sublingual nitroglyceryine (used for angina). Patient reported no change in pressure.

Assessment: Chest pain, hypertension

Plan: consulted with Dr. Fernandez

DX: sent patient to La Follette Hospital lab for stat troponin. Set up a cardiac treadmill stress test with thalium scan at St. Marys North for later this week.

RX: Imdur 30 1 QD (nitroglycerin tablets); 2 baby aspirins/day.

ED: Discussed potential cardiac origin of pain vs respiratory.  Told patient to start NTG and if he notices change in the quality, frequency, severity or duration of chest pain, go to ED or come to clinic if not very severe. 

FU 1 week, or sooner PRN

So again, very interesting to me.  He was a new patient who had not been seen for chest pain even though it had been occurring for about a year.  Up till about a month ago, it seemed he was having stable angina, which is chest pain caused by the heart not getting enough oxygen, usually due to exercise/exertion. The pain is relieved with nitroglycerine and/or with rest. It is often, but not always a precursor to heart attack, which is when part of the heart muscle dies because it is deprived of oxygen for too long. But now his chest pain occurs even at rest.  This is characteristic of unstable angina, which is chest pain due to lack of oxygen, not necessarily caused by activity, and not always relieved with rest.  This is very worrisome, and frequently precedes a heart attack. For this we sent him directly to the hospital for a troponin blood test. Troponin is an enzyme released into the blood when cardiac muscle dies.  This signifies a heart attack. If it is normal, the next step is to do a stress test, where he walks on a treadmill while hooked up to a heart monitor to see how his heart performs and tolerates exercise.  If this is normal, then it is unlikely that the origin of the chest pain is cardiac.  It could be respiratory, musculoskeletal, or even psychological.  But the heart is the first priority, so we start there. We should find out on Monday the results of the troponin level (if it was abnormal, he would have been admitted immediately, but we saw him at the end of the week so we didn’t get to follow up yet).

So we worked all week, then Friday night headed into Knoxville for dinner downtown.  Then we headed to that funky music venue Sassy Ann’s by the hostel for a 9:30 show by some crazy burlesque troupe—thought it would be interesting.  Well the one-man-band that opened for them, Shake it Like a Caveman, showed up an hour late and started playing at 10:30.  We had a drink, hung out till 11, and then were so exhausted we banged out of there before the burlesque troupe could begin their, uh, exhibition(ism).  We are old ladies apparently.  From there, we spent the night at our old stomping ground, the Knoxville Hostel, and hung out with our old buddy Al the hostel owner who was psyched to see us.  We are his favorite (non-shady) hostel guests. I slept like a baby in my old hostel bed, and we woke bright and early for another trek in the Smokies.  This time, we did an 11 mile hike, and I’ve got to say, my butt is still sore. (see http://picasaweb.google.com/shana.kaplan/Tennessee2008 for new photos).  After the hike we drove around Cade’s Cove, an area of the national park that was a settlement about 100 years ago.  It is supposed to be a great place to spot bears, but we only spotted a large bird (I say pheasant and Alayna says turkey), and two snakes.  The pics I posted of all the mountains (that all look alike) are all from the drive around Cade’s Cove.  I didn’t take pictures of the old cabins or churches because they just look like cabins and churches (yes I know the mountains just look like mountains, but are quite spectacular.)

On an unrelated note, people keep asking me why I want to come here when I finish school.  I hate feeling like I have to justify my actions and intentions, but I take comfort in the fact that when I finish explaining my motives to people, they say something like, “Wow- well I can hear it in your voice how much you love it.”

I do really love it.  I look forward to going to the clinic each day, and I wouldn’t even mind if my preceptor worked 5 days per week instead of four.  I’ve been pleasantly surprised how open the patients are to having students.  I walk into the room alone and introduce myself: “Hi.  I’m Shana. I’m a nurse practitioner student working with Mary. Would it be ok if I see you first and then she’ll come in?” Every single patient has said yes.  One mom double checked with me that Mary would also come in, and when I told her she surely would, the mom had no problem with me checking out her sick 7-year-old son. 

I truly don’t know what it is specifically about the REACHs Clinic in La Follette, TN that draws me in and makes me want to return next year when I finish school.  I don’t know if it is the gorgeous Appalachian and Smoky Mountians I look at every morning and evening on my front porch, and that I hike in on the weekends—there are beautiful mountains like these in New England.  I don’t know if it is the wonderful people who work at the clinic—I know that there are good people almost everywhere.  Or the patients, whom I look so forward to seeing each day.  Or the huge amount of learning I do every workday.

And not everything is so nice here.  There is overwhelming poverty.  At my clinic, only 22% of patients here have private insurance, 42% have Medicare/Medicaid, and 36% have no insurance at all—so why not work in Lynn, Massachusetts or Dorchester, or rural South Dakota where the statistics are quite similar. Why would I want to come live in a place where so many of the patients can barely feed their children, let alone pay for their medications?  Or where I have to see so many of my patients die slow and tortuous deaths from heart disease and diabetes? Or lung cancer?  Or drug abuse? I don’t understand how my patients cannot afford their medications that they can get for $4 at Wal-Mart, but can afford to smoke one or two or even three packs of cigarettes every day. 

It is a conundrum.  It is a frustrating role to be a caregiver to patients who cannot afford they care they need.  But it is so rewarding when things go right in a community where the odds are stacked against the patients. Sometimes they do take your advice.  Sometimes they do get better, and healthier. And knowing that I played a part in that is eternally satisfying—it is already and I am just an apprentice.

And even though I am but a lowly student, they act so appreciative to see me, as if I am the one doing them the favor.  They don’t realize that I am bettered because they are there.  For them, I listen to their stories, try to assess their needs, try to figure out how we can help them.  But from them I learn how to be a careful listener, an empathic person, a proficient diagnostician, and perhaps equally importantly, an advocate.  It is a powerful mutually-beneficial relationship we share, and I am eternally grateful.  Perhaps it is for this reason, to show my gratitude, that I wish to come back.

Hey Yall.

Week 2 has been great.  Last weekend Alayna and I went to the Smokies for a great 8 mile hike.   After that we headed to Sevierville (Dolly Parton’s home town) for the Bloomin’ Barbeque and Bluegrass festival.  That was loads of fun and loads of calories, but awesome after a long hike.  Alayna even got a picture with Dolly (well, her statue).

Sunday we officially moved into our new place.  Its great.  Its very spacious and completely furnished.  We spent about an hour at Walmart grocery shopping and picking up a few miscellaneous kitchen and bathroom items we needed.  The house does not have TV or internet, and I get really shoddy cell phone service there—so we’ve been getting some reading done and joined the two local libraries so we could check out DVDs and a jigsaw puzzle—We are so cool.  We keep really busy during the week, so it is nice to just relax in the quiet at the end of the day. 

The house is kind of up on a hill and overlooks the mountains.  I’ve still been really good about getting up early 3 days a week and going for runs, and there are a lot of great country roads to run on. There are very fe cars on the road early in the morning, but there are (literally) roosters crowing, cows grazing, woodpeckers pecking, etc. Its cool here in the morning, so perfect for running, and if I hit the road before the sun makes it over the mountain, there is beautiful mist that settles on the fields.  

I am still loving my clinical (as expected). I am constantly challenged and constantly learning.  Even the exams I expect to be routine (i.e. chief complaint: earache) often have a twist.  When people make appointments, they usually just state one problem but when the arrive they more often than not have about 7 issues to discuss.  Today a woman came in a few days after falling off a chair and injuring her wrist.  She had been seen in the local emergency room a few days ago where she was told it didn’t appear she had a fracture but to follow up with her PCP in a few days.  She came in today for a checkup and requesting pain meds.  She walked out of there without a with a diagnosis of arm contusion (recommended motrin), had a pap, and was diagnosed with post-menopausal bleeding and given a prescription for estrogen cream.  She hadn’t planned to mention her urinary symptoms, but I’ve gotten into (perhaps good/perhaps bad) habit of doing a quick review of systems regardless of the chief complaint, and so we stumbled upon a more pressing issue.

I was convinced that another patient had appendicitis.  She had severe RLQ tenderness and rebound, nausea/vomiting/anorexia, and a few other positive signs suggestive of the diagnosis.  Her WBC came back as normal, and a subsequent pap revealed severe cervical motion tenderness and right adnexal tenderness.  She was diagnosed and treated for pelvic inflammatory disease.  I’d never seen it before so I hadn’t thought of it—especially since it seemed so clearly like an appendicitis.

I am constantly reminded to stop before I leave a room and ask myself what I missed. I need to find the right balance of being thorough and being too thorough.  If I ask a patient who is there for knee pain if they are having any trouble going to the bathroom, for example, that may open a huge can of worms where there need not be one.  Then again, I’d hate to miss something important. 

I've seen 39 patients on my own this week (and written 39 notes!). My comfort level overall has definitely increased—I’m not a very nervous person, but I definitely feel a little self conscious about things with which I have little experience.  I’ve done a bunch of Paps this week, and am getting much better at them.  I seem to finally be getting the cervical experienceJ.  I heard an awesome aortic stenosis murmer the other day. One 14 year old patient I saw the other day said she hopes that I move down here because I am her favorite provider, and another patient yesterday scheduled her follow-up visit for a day that I come in so she can follow up with me before I leave. I even convinced a 78-year-old woman to who hasn’t had a pap in 15 years to have one (she was having vaginal symptoms, and has a history of cervical cancer but still has her uterus).

Also, I gave Mary my patient education tool for newly diagnosed diabetics that I created last semester for a class.  She said she liked in and would use it as a patient handout in the clinic!

Last night, we went over to Sheila’s house for dinner and the Celtics game (did they win?? I fell asleep) and tonight we are going out with some of our new friends from the clinic.  We are off to Nashville tomorrow for the long weekend to hear some amazing music, go to the Grand Ole Opry, and try out some country line dancing!  On our way back were going to stop and hike to Virgin Falls-its an 8 mile hike with waterfalls all along the way, ending at a large one. It is supposed to be one of the most beautiful hikes in Tennessee.

I’ve updated my photo page if you want to take a peek at our new home.  Hopefully I’ll have some good ones from this weekend.  http://picasaweb.google.com/shana.kaplan/Tennessee2008

This has been a whirlwind of a week and I am loving it! 

To refresh, I came down to Tennessee last summer through the National Health Service Corps Summer Search program, a federal program that sends nurse practitioner, medical, dental and physician assistant students to medically underserved communities to shadow someone in their future profession.  It is a recruitment tool in hopes that the students will want to return to work when they finish school.  Student applicants apply to the state they are interested in working in.  I chose Tennessee, because I wanted to go somewhere I’d never been before, and where I knew I would see a very different population and culture to which I am accustomed.  I was placed in the REACHs Health Center in La Follette, TN, which is in Appalachia.  I worked with Mary Morris, nurse practitioner who treated me like an advanced practice nursing student (though I had not yet completed by entry level nursing licensure).  This was wonderful for me, because I learn best when I am placed just outside my comfort and knowledge zone.  Lucky for me I am not afraid to ask questions, and Mary is not at all bothered to answer them.  That summer, to my surprise, I discovered my passion for family primary care, working with underserved populations, and I discovered an affinity for southern hospitality. I even switched my academic concentration from pediatrics to family care.  The entire staff and every patient I met was so welcoming and made me feel welcome and at home. It was very difficult and emotional for me to leave, but I knew that I would be coming back. 

When I returned to Boston, I finished my entry-level nursing courses and became a registered nurse, and then began my advanced practice curriculum.  Tennessee certainly prepared me very well for this coursework which I really enjoyed learning and seeing in clinical rotation through the semester.  Through the advanced practive portion of my program will complete five clinical rotations.  Our school encouraged us to do one over the summer, and they told us we could travel to do it.  I called up Mary (who I’ve kept in touch with during the year) and she said she be happy to take me back. The rest is history!

So I’ve been back for a little over a week to beautiful Tennessee.  I work with Mary Monday-Thursday (40 hours/week) in the clinic and have the long weekends off to enjoy the Smoky Mountains and all the music and arts festivals.  I came down her hoping to gain some insight into whether I want to move down here when I finish school, and after about 1 hour working back in the clinic I decided I do.  It feels very natural working with the patients here, and Mary and I have gotten into a rhythm.  Learning is very intensive, and I know that it is preparing me for when I am no longer a student. 

My first day, I shadowed Mary on all of her 21 patient exams. I had loads of questions as usual, but she doesn’t seem to mind.  The next day, I saw 11 patients on my own while Mary saw other patients.  After I see the patient, I report to Mary my history and finding and then we conclude the visit together.  Then I write up the progress notes which become part of the patient charts.  I really like that I’ve been able to establish trust with patients during just one meeting, and I look forward to seeing them again when they return for follow-up visits in the next month (and perhaps next year).  I’ve seen a few patients that I saw last year including a few that I thought about or worried about throughout the year.  I am really looking forward to having patients of my own when I graduate next year. It is very rewarding to have continuity of care.  

I am now seeing patients pretty much all on my own (except for a few Mary knows to be difficult or not good matchups for me) I have done one Pap and pelvic exam (which makes 3 ever) which I don’t really mind doing, but cant say I enjoy.  Perhaps it is because my fingers are too short—I just haven’t gotten the full experience J 

So our housing situation has been interesting.  We’ve been staying at the Knoxville hostel, but we’ve decided to move this weekend closer to work. The accommodations are great- the place is clean, there are plenty of amenities for a hostel, the location is great, and the hostel owner serenades us every morning with his good morning song (I could do without that one). But, we have about a 45 minute commute to work, and Alayna (the friend who came down here with me) works at a different place than I do and has very different hours so it has been a little tricky to juggle the one car.  Also, occasionally there are some shady characters that pop into the hostel.  We don’t feel unsafe but I think we’re ready for a change.   I will miss the cute houses in the neighborhood—I’ve actually been getting up early to go for runs before work a few mornings per week, which is very out of character for me, but I think I might like it.  Lets see if I can keep that up.

So anyway, I asked around at the clinic if anyone knew of anyone with rooms to rent.  The clinic CEO ended up letting us stay at a property the clinic owns.  It had been used as a group home for developmentally disabled adults, but they recently relocated to another facility so it is empty.  It is very clean, big, and totally furnished.  The location is perfect (about 5 miles from the clinic in a safe neighborhood).  The big downfall is that we have no internet there (how will we survive!!!) Also we are not allowed to throw big parties-too bad :) .  For the internet, there is a library nearby and one a half mile from the clinic.  I think we will be frequenting those places often.

When I told my good friend the other day that I really think I will move down here when school is done next year, her immediate response was “how will you meet a husband…and will you have a life?”  I don’t think either of those will be a problem.  I get along really well with the clinic staff—we are going out with one of the front-desk girls and some of her friends on Saturday night to go play pool—and June the triage nurse is already planning to set me up with a handsome urologist from Oak Ridge, TN.  It is true I grew up in a very different place and lifestyle than most people that I have met down here, but they are good people I think I will be just fine.  I know I can explain that to people up north till I’m blue in the face, but they don’t seem to get it.  Come on down and visit.  I bet you’ll love it too.  

Tomorrow we are off to go bear hunting (looking for them, not shooting them) and hiking in the Smoky Mountains, then perhaps a detour to Dollywood.  Have a great weekend y’all!

Hey everyone!

Thanks for reading again this year.  I am finally back in Tennessee for another 5 weeks, and so happy to be back. I've come back to do a clinical rotation for school credit.  I've kept in touch with my nurse practitioner Mary and Sheila (the nurse practitioner I work with a bit last summer who works mainly in the local school clinics and part-time at the health center where I will be), and Mary took me back to work with her again. 

It is now Saturday, but I left Boston on Monday evening and took my time getting down here. Monday night-Friday morning was spent in New York and New Jersey with my lovely Aunt Margie and Uncle Joe, Grandma Bea, Aunt Marian and Uncle Mayor, Cousins Larry, Ilene, Rachel, Leanna, Bella, and Peter (aka Simcha).  It is wonderful to have such great people en route!

Friday morning I picked up my friend from school Alayna at the Baltimore airport.  She will also be doing a clinical rotation down here working with Sheila.  We drove on down to Galax, (pronounced gay-lax) Virginia for the night, where we stayed at the Galax hostel on the Blue Ridge Parkway, overlooking the Blue Ridge Mountains. Gorgeous! We moseyed on into town for to BBQ and bluegrass music then back up to the hostel for the night.

This morning, we went for a little hike just over the border in North Carolina on the Cumberland Nob Trail, a gully trail with a bunch of stream crossings.  It was pretty steep downhill for the first half, and very steadily uphill for the second half, which reminded me I need to get my butt into better shape.  Then we took the back roads (including some dirt roads) through the countryside to get back on our way. 

Total miles traveled since I left boston on Monday—about 1075!

Tonight, we checked into the Knoxville Hostel where we will be living for the five weeks.   We were greeted by Al, the super southern and super friendly hostel owner, who ended us giving us the “2 cent” driving tour of Knoxville, which was actually really great.  The neighborhood we live in is really cute- with lots of little restored Victorian homes and hidden music venues.  He did warn us that prostitution isn’t that uncommon in Knoxville, so if men in pickup trucks honk and holler at us, just keep walking.  Good advice.  He drove us all around the city and gave us some history and some fun and practical info on where to go, what to see, and a little pop-culture (including about a Simpsons episode that took place in Knoxville).  He dropped us off in Market Square, the city center where we had a bite to eat.  Then we walked around and caught some live British invasion music (whatever that is) in a pub and then walked home for a somewhat early evening after a long day of driving.  We were honked and hollered at by 4 cars and pickup trucks on the way home, but we just kept walking

So I hadn’t planned on keeping my journal past my time in TN, but I feel that I have not let go of my journey down there so I don’t mind keeping it up. I probably won’t write very often, but if something seems like it fits here, I will certainly jot it down. I don’t even know if anyone still looks at this. I am also going to try to clean up the formatting and grammar problems from the rest of the journal.

Since I last wrote, I took a few days driving back and spent a weekend in New Jersey with my extended family.I have been busy back to work at Children's Hospital and running around doing various erands. 

I am feeling so “homesick” for TN. It is so strange. I felt so calm down there.  In the mornings I’d have coffee on the porch with Barbara (my roommate) and we’d just watch the birds and squirrels, and just enjoy the cool air.  In the evenings we often did the same, just talking about our days as the sky became dusky. I got so accustomed to that in my short time there, and I found that I love to spend my mornings and evenings that way.  Up here, there is so much noise and commotion all the time that I never noticed before. This morning I went outside to water the plants (that I just planted this week), and it was cool and quiet—like TN quiet and I loved it.  But it was 6 in the morning.  An hour later our street is filled with commuters, planes are buzzing overhead, busses are rumbling on the next street, and the serene morning is done.

I discovered tonight that you can listen to Merle 96.7, "Knoxville's only station for TOTAL country" online! I listened to it just about every day when I was down there, and I will say Boston radio has crap for country.  Anyway, I heard this advertisement on Merle tonight: "Merle playing the same songs over again would be like fishing for tuna in Norris Lake—not gunna happen!" I lived near Norris Lake (the picture of the dam below is Norris Dam) and I got to sing along with the jingles for Ray Viles Ford car dealership in Clinton: "You always get more, at Ray Viles Ford.” It felt very comforting to here the songs I heard every day and sang along to. 

I can’t figure out if this is an unhealthy longing to return to TN or a natural one.  I know that if I was to go down there right now, my role would be completely different.  I wouldn’t get to “play” nurse practitioner.  I don’t think I would be able to shadow Mary since I wouldn’t be there with the program I just finished.  I have been seriously thinking about going back maybe next summer to work, but I can’t figure out a way that it would make sense.  I will be a nurse by then, but the clinic doesn’t hire RNs, and it doesn’t really make sense to go get a job in the local hospital.  It isn’t La Follette that I miss.  It is the people I worked with down there and mood and feelings working with them evoked.  I looked forward to going to work every day, and enjoyed being there every single day.  I love learning, and it was almost non-stop with Mary.  I miss the mental stimulation, and our daily conversations about art, travel, gardening, food, and books.  And the rest of the gang there- Sue, Linda, Belinda, Bill, Dr. Burrell, Jane Barbara and of course Sheila. There are others of course that I would love to see, but these are the ones with whom I spent most of my time and I come away with fun stories and memories.

So if I go back there, I wouldn’t necessarily get to have that every day.  And I am not sure I want to be so close to that but not have it. I need to do a lot of thinking between now and then.

I planted a vegetable garden in my back yard.  I was inspired to try it when I was there. It is an experiment—let’s see if I can keep it alive.  People I am pretty good at, but I can’t keep fish alive, and I don’t have a good track record with plants. 

 
I am starting a pottery class Monday (Thanks Mary and Mary's pottery teacher!). So far, I am being pretty good about keeping in touch with people by email, and I hope to make a trip down there in September for a long weekend.

Even though I am missing TN terribly, I think I am a happier person than I was before I went there.  I think seeing how some people survive there has made me appreciate what I have and whom I have much more than I did before.  And I also find myself being a little friendlier to strangers than I previously was. I thank southern courtesy and hospitality for getting me in that habit.  The world can always use more kindness and I am happy I was reminded of that

The clinic wasn't too busy Monday, but I did get to see a really nasty set of tonsils that are coming out soon, and I learned all about trigger finger, a condition where the groove a tendon in the hand slides through becomes enflamed or narrower and the tendon can get caught on the groove, leaving a person’s finger as if they were holding a trigger on a gun.  Treatment for it is injections into the joint by an orthopedic doc so we referred her.

Tuesday was my last day at REACHS.  I made a big effort not to get sad about it until the end of the day.  We were really busy, which helped, and I had a few really interesting cases, particularly in the afternoon.  I did a bunch of exams on my own today, and am really pleased with how comfortable I am with it (except for the teen male physicals) and how much I enjoy doing them.  So often, a patient comes in with one complaint, and with a little prodding from the provider, you find a much deeper, bigger problem that the patient hadn’t initially wanted to discuss.  It is challenging to figure out what the real problem is, and I do love a challenge!

One 21-year-old woman came in because she was having severe panic attacks whenever her fiancé was away for work, which had been during the week for the past month.  She said she was throwing up, losing weight, feeling depressed, waking up in the middle of the night feeling like she couldn’t breathe.  She wanted to quit her job because she was so anxious.  She said the moment he got home, she felt great but as soon as he would leave, she would get anxious again. We gave her some meds for anxiety and nausea, and sent off a bunch of labs to see if there was a physiological reason for the symptoms.  As it turned out, her thyroid was really low, so we called her back in.  I’ve noticed that a lot of people come in with new-onset psych problems and they think they are going crazy, and of course that makes them even more nervous or depressed. Then a lab test shows that there is a physiological reason for their illness and they immediately feel relieved. It is amazing what an improperly working thyroid can do to a person.  That is something they haven’t stressed to us in school, but it seems like a large number of the patients here have hyper- or hypothyroidism. I don’t know if it is endemic to this area, or if this is representative of everywhere.

I also met a woman who has a rare disease called hemochromatosis, where the body absorbs and stores too much iron, which can damage the organs, especially the liver.  It can either be hereditary or caused by other disorders.  In her case, it was caused by alcoholism.  Treatment for it is simply donating blood.  They give a pint of blood 1-2 times per week for months to a year, and then every few months there after.  Periodic labs must be done to check for blood iron levels.  She came into the office for chronic knee pain and swelling, a sty in her eye, and on exam, she had an extremely tender right upper quadrant of her abdomen.  She says she has been drinking about 12 beers a week (which is contraindicated with her condition), and she wasn’t allowed to go to her hematologist anymore because she had missed too many appointments so they kicked her out of the practice.  Her labs showed extremely elevated iron in the blood, and the abdominal tenderness suggested liver inflammation or damage.  We referred her to get a liver ultrasound, lay off the booze and to show up to her doctor’s appointments.

I also got to see Ricky, the hypochondriac I have seen 4 times in the past month.  This time for a lump on his head, which neither Mary nor I could find.  He also reiterated his concerns from the last few visits while he was there, and Mary did her best to assure him he was not dying.  He knows how irrational he is being.  He says it takes over his life and he wouldn’t wish it on his worst enemy.  He is in therapy for it.  Do these people ever get over it?  I also met his wife who was in for migraines (real ones), and she was lovely.  Very patient.

One of my last patients, which was also my most difficult, was a 31-year-old woman who hadn’t been for a physical or any other care in three years since her third child was born.  She had felt a lump in her breast and had some bloody discharge from her nipple a few days earlier.  Over the past few days, the lump had become very painful and the pain had spread over to under her arm, which was so tender she couldn’t put on deodorant. Her right breast tissue was much denser than the left, but I believe I felt the lump she was feeling, and perhaps another.  She has a high risk for breast cancer.  Her sister, aunt and grandmother all have it. She’d also had some really severe cervical dysplasia a few years ago that was lasered out, but she never went back to have a follow-up pap. She doesn’t like doctors.  We referred her to the Breast Center in Knoxville, which is supposed to be one of the best in the country.  She was a new patient to the office today and she isn’t too good about going to her provider, so I don’t know if she will come back to the clinic for care.  I hope she will be ok. I think I will be thinking about her for a while.

Most of these patients came in at the end of the day, so I didn’t get a chance to write my notes till then.  I said my difficult goodbyes to Mary (who I am going to miss the most) and the whole crew and shut myself up in her office to finish my notes. Sue, the nurse who assists Mary, came in to give me a big hug and say goodbye and I just broke down.  I am not ready to leave yet.

The office closed at 8 and I hadn’t finished writing up my notes yet, so I packed up my stuff, and decided to finish at home and bring them back in the morning (not the patient charts, just my notes).  So after all those hard goodbyes, I would get to do them all over again in the morning!  As a drove home for my last official evening at REACHS, my eyes welled up.  This has just been remarkable for me.  I have gained so much, not only in nursing and medical knowledge, but about myself, what I want out of my career and my life, and I have met some very dear people. And I leave them all tomorrow. When I got home, Barbara had some family members over for dinner, and of course I was a little mess so I had to excuse myself for a bit. Barbara's sister Diane was there. She is the CEO of REACHS and said she had heard some good things about me from the clinic staff, and to call her in 2 years if I was interested in a contract.  I just might. 

The past two days have been really busy, so I’ve gotten to pack a lot of learning into each day.  Mary is letting me do adult exams on my own now instead of just the kids.  I love doing the adult exams, but now there is a whole new set of questions I have to remember to ask that I didn’t need to do with the kids (i.e. did you get your mammogram? When was your last pap? Did you have your colonoscopy? Have you ever had a bone scan? Are you still smoking? How much?, etc) As always, when I come out of the room I find Mary and present the patient to her.  She now has me quite well trained to ask these questions, and I am grateful for that.

Some highlights: Felt a thyroid nodule, met a schizophrenic who wanted antibiotics because his teeth had all rotted out, and saw erythema nodosum, a pretty rare rash that causes painful tender lumps below the knees, often secondary to another infection.  In this case, it was secondary to strep throat. I met a man who had very vague symptoms of Lyme disease (had a tick bite 2 weeks ago he thinks was on for a while), many of which could also be symptoms of depression (father passed away the day before he noticed the tick bite).  He had had about a week of feeling overwhelmed and depressed, muscle aches, fever, sweating, passing out, dizziness, vomiting, dehydration and a few others. Clearly the fever isn’t from depression, but depression can manifest in physical ways such as several of his symptoms.  It is very difficult to the source of the symptoms by taking a history alone.  We ran several tests, including blood work, thyroid panel, B12 level, vitamin D level, urinalysis and others.  I don’t know how this one turned out.  I hope Mary will follow up and let me know how the patient did and what the tests revealed after I leave. I also saw a middle aged man with a classic presentation of a new case of gout, which I’d not seen before: his left knee and ankle joints were extremely swollen and tender. No other joints were affected. The most interesting one was a patient who has Kartagener Syndrome, which is when the major organs are on the opposite side of body, so that the heart is on the right, liver on the left, etc., and patients also have chronic sinusitis, bronchiectasis (dilation of bronchial walls secondary to inflammation or infection) and incompetent cilia. When I walked into the room, I thought the x-ray was backward, but on exam, you hear that heart sounds are significantly louder on the right side than on the left.  It was very cool (for me, not him).

This weekend was very low key.  Friday I went to Rugby, this old English settlement that has a present population of 85 people.  Many of the original structures have been restored so it is kind of cute.  There wasn’t much there, but a few weeks ago they had the Rugby Festival where they do all sorts of old English games and crafts and such. That is supposed to be neat.  The history is kind of interesting.  In the late 1800s, some rich English gent teamed up with a land ownership company in Boston (who owned the Rugby area) and created Rugby in hopes that it would become a utopian English society in the middle of Tennessee. Unfortunately, most people got typhoid fever and died, but a few remained to keep the town going.  Now some of the residents are descendents from the originals, and others have moved in on the beautiful land.  All the structures that are built in Rugby must meet certain standards and must resemble the original architecture of the town.

Saturday I did Nothing.  Like really nothing.  I lounged around all day, ate some food, watched TV, read some, and went to bed.  Nothing. It was kind of boring, but also kind of nice.

Today, I went to my NP Mary’s house for the afternoon and dinner.  She and her husband designed the house, and it looks like it should be in Home and Garden Magazine. I wish I took pictures.  I told Mary that when I have a house someday, she is going to design it.  There is just so much light and creativity inside, with her beautiful artwork everywhere, her art studio (currently working on stained glass), plants, huge windows, and her gardens.  She lives on a 50+ acre plot that she grew up on, and years later moved back to.  She has planted over 900 walnut trees, 1100 cypress trees, grape vines, apple, apricot, and pear trees, bamboo, insane amounts of flowers, ferns, etc.  She has hiking trails, a barn with 7 peacocks, 2 dogs, and 5 spring-fed catfish ponds.  The place is like a retreat.  If you ever need to get away from it all, go to Mary’s.  Plus, she cooked me the most delicious dinner I’ve eaten in as long as I can remember, and the salad came right out of her garden (which I picked!) Its just one of the most beautiful, peaceful places, and I hope someday to have a place like that.  Mary and her very nice doctor husband Gary do all the work themselves on their property. I don’t know if I’ll ever be that ambitious, but perhaps I’ll tend the vegetable garden, and we can hire a gardener for the rest.

My only complaint is ticks.  I’ve never had any on me before today, which is surprising considering how much time I spent in the woods as a kid, but tonight I pulled THREE off me! One on my upper arm, one on my upper thigh (pervert), and one out of my hair. I feel so violated…those little nasties sucking on my blood.  Now I am scratching and itching all over like crazy, which is stupid because I didn’t feel any of them bite me and they don’t itch. I do not believe they were on long enough to spread their disease (I’m told it needs to be on there 36-48 hours). I had my roommate check in my hair and she didn’t see anything, but I think I will have someone look tomorrow too.  And to think I was just getting over my mental head lice, and now I have mental ticks. 

EW! EW! EW!

This morning I went back to the Children’s Center.  Sheila (the one I work with at the schools and also the one who first brought me to the Children’s Center) had a family emergency so she asked if I could take her place at the exam.  She was not doing the exam, just assisting.  It is required by law that there is another medical person—doesn’t have to be a nurse—in the room.  Gail was the examiner last time I went there and was as well today (she is the only certified pediatric (under 13) S.A.N.E. nurse in the surrounding 6 counties.  Sheila is going through the certification for pediatrics currently). 

Today’s exam was on an 8-month-old girl. There was no sexual abuse suspected for her, but her 3-year-old sister alleged that her father had molested her (and supposedly a rape kit done at the local ER confirmed that), so they have to check the baby just in case.  Fortunately, there was no evidence of sexual abuse.  The only sign of abuse/neglect were several labial adhesions.  Basically, this means that the flaps of labia had gotten stuck together, and then eventually, skin formed over them and sealed the labia shut.  It can be completely closed so that there is no opening to the vagina and urethra, or in can be partially closed, with one or more openings in the labia.  Fortunately, this little girl’s was partially closed, and can be treated with a certain type of cream that is supposed to separate the conjoined labia, or sometimes it is left alone and it resolves by itself.  This can be congenital, but it also happens with poor hygiene—if parents are not cleaning the baby well.  Gail suspected this was the case. 

It was also clear that this exam was much less traumatic for the baby that an assault exam is on a teenager.  It was barely more than having a diaper changed.  If you could keep her distracted with stuffed animals and toys, she didn’t mind at all.  If only that were true for the teens.

The child was in the custody of her aunt and grandparents.  The aunt brought her in today.  She was so loving toward her.  I really hope this little girl stays surrounded by people like the aunt, and has a chance of escaping the cycle and lifelong problems that go along with child abuse.

The other thing that I thought about today is child development. This was an 8-month-old who was able to sit herself up, and could stay standing up if someone was holding her hands.  Yesterday in the health clinic, we received a fax from the department of health about an 8-month-old baby I’d seen twice the previous weeks for vomiting and dehydration.  (This was the family with 21-year-old mom with five kids she wanted to “whoop” but the state wouldn’t let her.  The only time she held the baby was when we needed to look is his ears, nose, and throat. Otherwise, he was laying in his car seat on the floor). The notice said that he was not sitting up on his own, a developmental landmark that should be achieved by 8 months, but usually happens at t 4-7 months. I had asked Mary about why he would be delayed and she said it is probably because he does not get enough attention and stimulation.  If he is mainly left in his car seat in a reclining position, he will not develop the appropriate muscles and motor skills to meet his developmental markers. I left a message for one of the case managers at the downtown office who does parenting classes in hopes that she can provide resources and education for that young mom, who clearly needs help. What else can you do for that?  You can tell her she needs to play with her baby more, but she can barely keep tabs on her other 4.

“TURN YOUR HEAD AND COUGH”

I learned all about that today.  I also learned that 17-year-old guys are NOT my favorite population to work with, and I imagine 24-year-old girls are not their preferred providers for physicals. And he didn’t look happy when I asked him, in front of his mom, if he did a monthly testicular self-exam.

This kid came in for a routine physical, but man it was like pulling teeth getting him to talk.  His mom gave me most of the history because he wasn’t in the mood (although I don’t know why she was in the room for his physical in the first place--he is a big boy ).  His only concern was that his ex-girlfriend had genital herpes and he had an outbreak 9 months ago of what appeared to be herpes as well (He didn’t come in during the outbreak, so they didn’t culture his sores).  He hasn’t had any outbreaks since, but he didn’t understand that he may have herpes and can spread them to other people.  Try talking condoms to a 17-year-old kid in front of his mom…not to mention mom’s facial expressions during all of this.

I did not do his testicular exam- saved us both the embarrassment (haven’t done them before on adults and hadn’t learned how yet).  I had Mary do it when she came in to finish up the workup.  I am quite sure having a middle-aged woman do the “turn your head and cough” while a 24-year-old girl and his mom are in the room was NOT the highlight of his day. 

So I made a pretty big decision this weekend.  Country music apparently brings me mental clarity.  I have decided to change my specialty from pediatrics to family medicine. I wrote a letter to my school today, and I hope that I will be able to make the curriculum switch. 

I love working with kids, especially the elementary school age group.  They are my favorite population to interact with.  They love to show off their independence and knowledge, they are silly and imaginative they can be brutally honest, they are actually malleable—they sometime listen to what you teach them, and they are just plain fun. But, I have found in the last few weeks, that I really like working with adults.  Their routine medical problems are much more interesting to me than the pediatric ones.  To my utter surprise, I don’t even mind working with the elderly—something I always thought I would really dislike (and do dislike in the inpatient hospital nursing role). I don’t want to compromise on either my favorite population or medical problems that are fascinating because they are complicated by years of poor access to care, not treating their bodies well, non-compliance with medicines and diet, and genetics catching up with them.

I told Mary today about my decision, and how she was the primary influence on it.  She was thrilled and kind of paraded me around the office with a big smile, sort of bragging, “Guess what?  Shana wants to be a family NP now!” She had been doing a lot of teaching with me on specific things to keep in mind, but it had mostly been pediatric stuff.  Now she is filling me in on a lot more that is adult-oriented like certain drug interactions, tests that need to be done for certain symptoms or drugs, arthritis treatments, how to read chest x-rays of smokers, etc. 

It was pretty busy Wednesday.  I saw 22 patients including two pedi physicals.

I think I mentioned this before, but it is really neat when I get to see a patient, and we tell them to come back in a week for follow-up, and then a week later, I am still here and I get to see if and how the problem resolved.  That is really rewarding for me, and something I never get to do in the hospital. I have previously seen about a third of the patients we saw today, and it is really nice to walk into a room and have patients recognize you. I feel a little attached, like they are my patients.

One patient came in from home with tachycardia (fast heart rate) at 172 beats per minute (normal is 60-100).  She said she felt non-specifically crappy, but didn’t feel short of breath, dizzy or have any chest pain.  She is severely overweight, has diabetes, hypertension, high cholesterol, and the rest of all that goes with those problems.  We did an EKG which showed sinus tachycardia.  O2 sat was 96%. Respirations were normal. We sent her by ambulance to the local ER.  The two MDs in the office have admitting privileges there, so one of them went and saw her the next morning.  She still had a slew of tests to do, but the physician feels she has a pulmonary embolism (blood clot in the lungs).  In the ER her O2 sat was 86% and she had minor unilateral swelling (We didn’t see that in the office).  I was really surprised that she suspected this because I thought symptoms of a PE were always chest or respiratory related.  Her only symptoms in the office were tachycardia and generally feeling like crap. We hopefully will get the report in a few days with the confirmed diagnosis.

We also saw a middle-aged male who is a severe hypochondriac.  He had been in a few days earlier for a follow-up on his chest cat scan that had shown a benign cyst on his lungs. He was terrified he was going to die, and needed reassurance that he did not have cancer.  It was so sad because he was not able to accept that he was fine.  Mary would reassure him that the results of the scan were accurate and he didn’t not have cancer, and he would ask again, “so you are sure I don’t have cancer? That is what this shows?” and she would reassure him. And he would say ok, start to leave, and then ask again. This whole dance took about 20 mins of him repeating his question and her reassuring him that he was ok.  He came in again today complaining of his neck feeling different on the left side when he felt it with his left hand compared to his right hand. He was freaking out again convinced that he was going to die. Mary and I both felt his neck and assured him that we did not feel anything or any difference from one side of the neck to the other, and if it felt weird to him, it was probably because he was coming at it from a different angle with the two different hands. We reassured him over and over, probably over 20 times.  We’d feel his neck, say it felt totally normal, tell him he was ok, and he would get ready to leave and say, “Can you just check it one more time.  Do you know what I mean?  It feels different with this hand than with the right one.” Over and over and over.  He was trembling because he has such high anxiety (yes he takes anti-anxiety meds).  It helps him leave if Mary writes him a note on her prescription pad that says something like “I inspected John’s neck today and found no nodes or abnormalities.  His neck feels completely normal.” How sad! This poor man cannot work because of this disease.  He is bound to give him self a heart attack at some point from all this worrying.  He is married too. I wonder what made him like this.  There must have been some medical scare at some point in his life that did this to him.  It is completely debilitating. He is in therapy, and knows his worries are irrational and that he is a hypochondriac. Yet he cannot help himself.  I am sure he will be back soon in a few days.

Tuesday morning I woke feeling like a  90-year-old granny.  My hips were killing me from the previous day’s trek, but it was an easy day at the elementary school clinic so I kept my moaning to a minimum.  So far, the clinic hasn’t been very busy.  Since school is out, they are not getting the sick student population (or the kids who want to go home to watch cartoons population) that usually keeps them busy, so Sheila and her gal Friday DeShea spend a lot of their time going through patients’ charts and calling in kids who have physicals due.  They sent flyers home with the kids at the end of the school year about the clinic’s summer hours, and we put up a few at the local drug stores, grocery store, post office, and bank.  Hopefully soon business will pick up.

I did see a handful of kids though, including three siblings who were sick. Two had strep (which we discovered after I swabbed their throats—never done that before!), and the little one had an ear infection.  Antibiotics all around!  Sheila taught me about appropriate antibiotics and how to dose them for kids, and she even had me write the prescriptions (with her supervision and signature, of course).  Doing the throat cultures and writing a prescription may seem like simple tasks, but for an amateur like me, feel monumental  Sheila is a master at doing the throat cultures without making the kids cry (bribery helps) so I hope some of her skills will rub off on me.

I have a really tough time reading ears.  I certainly can tell if there is wax, blood, tubes and other obvious findings, but I am not so good at seeing middle ear infections.  She explained that a healthy ear has a really nice cone of light reflected off a smooth shiny eardrum, and you can see the ossicles (the bones involved in hearing) behind the drum.  Kids’ eardrums (tympanic membranes or TMs) are often hard to see because the canal is narrower and curved a bit and you cant put the scope in as far as you can with adults. Sometimes you can easily see a fluid line behind the TM, and sometime you can’t.  The light reflects differently if there is fluid behind it, so you won’t see that nice cone of light. I looked at a bunch of pictures of normal and abnormal ears, but I still find them tricky to read. There is a Boys and Girls Club at the school for the summer, so next Tuesday, she is going to have me check every child’s ears so I can learn it (nicest set of ears wins a prize!).

Like at the health center, where most patients walk out with a goodie bag of med samples to save them on the drugstore costs, at the school clinic, every kid walks out with a (donated) toy for being such a good patient. They also give the parents some kids clothes if needed. As awful as it must be to live in poverty like people do here, it is a blessing to be surrounded by so many caring, generous people. One of my coworkers here called my month down here a mission trip.  I hadn’t thought of it like that, especially since I am getting so much out of it, but I think now that everyone who works down here is essentially on a lifelong mission trip.

This is a long one, I warn you. 

Yesterday was uneventful- kind of a slow day: 15 patients/four pedi. I did a lot of urine analyses for various infections.  If they come back positive, then spin the urine in a centrifuge to separate all the liquid from the sediment. Then we dye the sediment and look at it under a microscope. I love looking at things under the scope—that is something I’d like to practice more.  I am good at preparing slides, finding things and getting them into focus and all that, but I have a hard time identifying things. I am good with white and red blood cells and certain types of bacteria, but I still have a tough time figuring out which are skin cells or just “junk” (just debris from the cup, slide, sample, etc) versus bacteria or yeast or something. If one of the nurses focuses in on a piece of yeast and tells me look at its buds or shows me  trichomonas (aka “trick”) and points out the tiny little flagella (like arms for swimming), I can see it, but I wouldn’t have found it on my own.  I need more practice. 

I did get to do a physical on the 14-year-old girl I saw last week for the sexual assault exam.  I think it actually worked out well for her, because I went in by myself first and didn’t have to put her through the entire questionnaire again (that Mary would have if I hadn’t been there) since I had heard it already last week.  She didn’t have to do the unclothed part of the exam again either.  And she already trusted me so it made the whole thing easier on both of us.

It got a little tricky (as I thought it would) when I had to give Mary my report on her.  Mary had heard it through the grapevine that the girl had been sexually abused by her father and that she was supposed to be in counseling at the Children’s Center, but was not aware that she had been there last week for the exam.  So when I talked to Mary about her, because of confidentiality for the Children’s Center, I felt like had to give Mary a report that prompted her to ask me questions rather than me just coming out and saying what I knew.  I am not sure if I needed to do this since the girl was now under Mary’s care, but on the other hand, the Children’s Center does not usually share patient information with the health clinic. 

Today there were a few really interesting cases (lots of medical lingo):

Case #1

The first was a middle-aged woman who last night had an episode of sudden-onset shortness of breath, chest pain, and she says her blood pressure “shot up in my head” and “it felt like it was going to explode.”  She said she became very confused and her kids told her she began talking about her dead mother coming over for dinner (as if she was still alive).  The kids took her to the ER where they checked for blood clots and a heart attack. CBC, EKG, chest x-ray and troponin were normal. They wanted to admit her but she refused.  Today, on exam, she had generalized weakness, neuropathy in her feet (no sensation just on the pads of her toes), and her tongue trembled significantly when protruded. She also had some unsteadiness when walking heal to toe. Today, no chest pain, shortness of breath, delirium, or other pain.  Only the weakness and unsteady gait.    Also she was seen 3 months ago with an elevated ESR at 130 (should be less than 20). She was sent to a hematologist but somehow he missed that and for some reason it wasn’t followed up on. She takes Seroquel (an anti-psychotic) for depression and klonopin for anxiety. We learned today that her klonopin ran out 4-5 days ago. Abrupt withdrawal symptoms can include convulsions, psychosis, hallucinations, behavioral disorder, tremor, abdominal and muscle cramps, so that might account for what happened last night. It does not account however for the elevated ESR Rate.  She does not have rheumatoid arthritis. Often that is indicative of cancer such as Hodgkin’s disease or multiple myeloma. They sent her blood off for more tests and sent her for a carotid Doppler study to rule out a TIA (my initial thought).  Any thoughts?

Case #2

An elderly female with severe rheumatoid arthritis came in today for severe neck spasm.  She was unable to move her head in any directions more than a few centimeters, but could not recall any injury. She was immediately sent to the local hospital for a c-spine x-ray. I learned that in patients with RA, a rare but very serious condition called atlantoaxial subluxation can occur where the joints between C1 and C2 (top 2 vertebrae, responsible for head turning) thicken and compress the ligament that stabilizes these 2 vertebrae.  If the ligament is compressed or even severed, the spinal cord will also be compressed and possibly severed as well. Approximately 11% of RA patients experience some degree of cord compression from this, so if they complain of neck pain, don’t just give them a muscle relaxer and tell them to use hot compresses. Very interesting.

Case #3

3 months ago, an 18-year-old female was seen for decreased sensation and pulses in her feet.  Her feet at times appeared dark red to purple and had extended cap refill.  She appeared otherwise healthy. No known patient or family history of venous/arterial disease, diabetes, clotting problems, etc.  She smokes less than a pack of cigarettes per day.  She is not overweight and her other standard blood work was normal except for a critically low B12 level. The health center got this lab result after she had left so they tried to call her back in for B12 shots. They had sent her to the hospital for studies, and then she seemed to disappear off the face of the earth.  Her phone had been disconnected, letters the health center sent her were returned unopened, and she never came in for a follow up.  So she hobbled in today asking to be put on birth control pills.  Mary was quite happy to see her alive, but frustrated when she had no excuse for not following up on her last appointment.  On exam, both feet were very dark red with cap refills of 5-10 seconds.  She said they sometimes felt crampy (probably in part because of the B12, but probably not totally due to that).  She had decreased sensation on all her toes and no sensation on the bottoms of her large and small toes.  Her calves were somewhat red, but not as much as her feet. There was no edema. On her left foot she had a very diminished dorsal pulse and we couldn’t find the posterior tibial pulse.  On her right foot we were unable to find any pulses (there was no Doppler available at the clinic for pulses).  We gave her the B12 shots and set her up on a schedule for those, and told her to take a baby aspirin every day to prevent clots. Her lab work was sent out, and she needs to follow up in 1 or 2 weeks (I forget which). Mary is concerned that she will go elsewhere to get birth control, so she warned her that with her smoking and her obvious blood vessel problem, she could die if she goes on the pill.  Hopefully she will listen.  Any ideas on this one?

Here is a copy of a S.O.A.P (subjective, objective, assessment, plan) note I wrote today for another patient:

Patient’s Name: _______________ Chart #______________

Meds: none     Allergies: none

Wt: 139 lbs      BP 109/74       HR 78  T97.5

S: 21 y/o F c/o irregular periods X few weeks. Reports 4 episodes vaginal bleeding lasting 5-6 days each in the past month. Reports heavier and more frequent bleeding and cramping, and also cramping between bleeding episodes. Also reports cloudy vaginal discharge around periods. Says she had regular periods prior to her pregnancy.  After her son was born 9 months ago, she was given 1 depot shot. Wanted to switch to BCP but pt’s mom had blood clot and was told she had a clotting disorder. Pt received no further birth control.  Pt said periods then became regular until 1 month ago. History of +HPV and cervical dysplasia. Had laser ablation treatment in Nov. 06. Was told to have repeat cervical exams Q3 months but has not because no health insurance. Pt also says she does not get enough calcium or do breast self-exams.

O: U/A and CBC normal, negative HCG (pregnancy).  Pap done.  Some inflammation where ablation done in November. Exam otherwise benign.

A: 1.  Irregular periods
    2.  R/o clotting disorder

P: Thyroid test pending, follow-up appt. in 2 weeks for results of Pap, find out about mom’s clotting disorder and test patient for it. Encourage calcium supplements, multivitamin, and breast self-exam.

Do I sound like I know what I am talking about yet?

May 20 , continued.

I also went to a local power supply/ tourist attraction Norris Dam today... no good story attached to that, but cool picture:
 

Here are some photos of where I live:

The view from the driveway-- Love those mountains!

And these are a few of the cows that live in the field behind the house
My Roommates:
Buttons
 
And Barbara (but not her cute grandbabes) 

This is downtown La Follette, where the health clinic is.  It looks really cute, but if you look up close, most of the businesses are closed down.  There are very few jobs here.
  

So I failed at sleeping in on Friday, but hey, I am not here to sleep.

I was woken up by a call from Sheila, the NP I met the other day. She told me she had just been called to the Children's Center to do a sexual assault exam on a 14-year-old girl, and asked if I wanted to be there. I did, so I hurried over there (the exam was scheduled for 30 mins after she called me).

I walked in and the girl was actually one of my patients from the clinic who I'd seen on Tuesday or Wednesday for headaches. Anyway, since the girl sort of knew me, she felt comfortable having a somewhat familiar face in the room. The short story is that she alleged long-term sexual abuse by her father. Her mother told her she didn't believe her and kicked her out and now she is living with her grandparents. Since this was not an acute situation (the girl had been abused over a long period of time, but not since she started living with her grandparents), the exam was fairly short. The nurse in charge, Gail, took several cultures and photos and some blood. The cultures and blood are to test for STDs, which are really common in kids who have been sexually assaulted. The girl tolerated the exam really well. I had previously mentioned that the center does a nice job making the exam as bearable as possible. The exam room is very child-friendly with murals on the walls. Rather than an uncomfortable paper gowns and drapes to cover the patient, an organization called Project Linus(http://www.projectlinus.org/about.shtml) donated an entire closet full of hand-made quilts that the kids can choose from, and they get to keep the one they pick.

It is interesting: confidentiality prohibits me from telling Mary my NP that I saw this girl at the Children's Center, but it seems so strange since we saw her not 3 days ago in the clinic for a sick visit, and both the Children's Center and the Clinic are part of the same organization. Yesterday, on my day off, while I was out and about, I saw three of my patients and one of the nurses from the health center. One patient was at the Children's Center, a patient and one of the nurses at Wal-Mart, and one patient at a gas station about 15 miles away. I can't get over how small this area is. In Massachusetts, I don't think I have ever run into 4 people I knew on the same day. And now I am in Tennessee and I barely know anyone, and it happened my first week.

After that, I drove 30 miles out to Oak Ridge, TN. I briefly mentioned it yesterday: back in the early 40's, the US government kicked out the residents of several towns where Oak Ridge is currently located and built an entire city dedicated to the WWII effort. Everyone in the town worked in some way either supporting the town or the war. The government constructed several top-secret facilities which are still standing today where they developed techniques to enrich enough Uranium to make the bombs that were dropped on Hiroshima and Nagasaki and ended WWII. At the time, Oak Ridge was called the Secret City. It was not on a map, the high school football team was only allowed to play at away games, no one could enter or exit the city without going through a government check point, and no one was allowed to talk about their jobs to anyone inside or outside of the city. Most people did not even know that what they were building was to go toward making nuclear weapons.

Anyway- the history of the city was really interesting. I went to the Museum of Science and Energy there that has a great exhibit on the history of the city and the war. Then I went on a driving tour. The gift shop sells audio CDs that you put on in your car and it tells you where to drive as it describes the history of what you are looking at. It was really neat. A lot of the original houses, city landmarks, stores, restaurants, and government buildings are still standing and are in excellent shape, and most of them are still in use. There is currently still a huge amount of government and non-government atomic and other scientific research being done. The town is also home to one of the most famous rowing courses in the country.

Today was especially nice! I got up early and drove 45+ minutes to a grocery store in Alcoa, TN. Here I met 11 members of the Smoky Mountain Hiking Club and went with them on an easy hike in the mountains. I really wanted to go hiking but not by myself. It was SO relaxing. It was a really easy trail (I was the youngest person on the hike by at least 30 years, but I am kind of an old soul so it was ok with me), but I felt so rejuvenated. After driving so much in the past week (1,400+ miles), it was wonderful to be away from the sounds and sights of the highways and really stretch my legs. Whenever I am in the woods and feel really intertwined with nature, Thoreau's famous quote always pops into my head "I went to the woods because I wished to live deliberately...I wanted to live deep and suck out all the marrow of life." I don’t go there to live deliberately, but when I am there, I am reminded how beautiful, delicate, and exciting life is. I think everyone needs a little of that now and then.

Smoky pics 

Today was much slower at the office but still good. My NP Mary is a family practitioner, but prefers working with adults (which isn't too big a deal since it is mostly the older adults that get sick), so she is more than happy to let me to go into the pediatric rooms first and do the exam, and then she can just go in and finish it off.

I saw five pedi patients today”

-A 7-month-old who I saw yesterday for 13 days of a stomach bug who came in for a follow up and is doing much better than yesterday. I also saw his three year old sister who is getting the bug and was also complaining of ear pain. Both of them, plus the mom and the other 3 kids also have some rash (looks like ringworm) that they just discovered today. This is the 21-year-old mom with 5 kids under 7 years old that came in yesterday. She brought all 5 into the room and the only one who behaves was the 7-month-old.  The other 4 were screaming and tearing things, playing with/throwing the covers to the ear scope, climbing on the counters and exam tables, and putting thumb tacks into their mouths, and all mom can do is scream right back at them. It is a miracle one of them didn’t fall and split their head open. At least they would have been in a health clinic.  "I want to whoop them," the mom said. "But I already had to sign a thing saying I wouldn't beat my kids no more. The state thinks I abuse my kids. I don’t abuse them. I just can’t control em."

There was a 17-year-old boy complaining of headaches. He is a football player, who on Thursday hit another player head on and lost consciousness. Saturday he got the worst headache of his life, had a nosebleed with it, and lost vision in one eye for about 5 minutes. He never went to the hospital. Came into the clinic today (8 days after the injury!) for the headaches and some really severe neck pain. As soon as he told me that, we sent him right over the ER to get a CT scan and neck x-rays. I should get a follow-up on Monday. He didn’t want to see a doctor because he was afraid they would make him stop playing football. Golly! as they say down here.

The other child was a 12-year-old boy with a 1 cm abscess (infected sore) on his belly. He thought it might be a spider bite but couldn’t remember being bitten. Dad thought it was a zit that ruptured because the boy didn’t wash himself well or often. We cultured the wound to see what it is infected with (that will take a few days). However, he has a prior history of MRSA infections and his mother is currently in the hospital for a major MRSA infection, so we put him on Ceftra to treat it.  MRSA stands for Methicillin-resistant Staphylococcus aureus, which is a really NASTY bacteria that is not killed by most antibiotics. Even when the patient is treated with antibiotics that do kill it, it often recurs and may develop other resistances, making it even harder to get rid of.

A teenage girl was complaining of weight loss, fatigue, headaches, low blood pressure (84/60), and 2 episodes of fainting. We sent out a bunch of labs, and we will get all that on Monday. This one was really interesting to me, because it could be any number of things, and given her age-related TTBD (teenage turkey brain disease, as my stepfather calls it), it can be very difficult to get answers out of her. Some things we think are possibilities are mono, type 1 diabetes, eating disorder, not getting enough sleep, depression and drugs. Any other thoughts?

The rest were 8 middle aged or elderly people complaining of pain, dizziness, worsening congestive heart failure, swelling, fatigue, etc.

Even though I am in the pediatric track in school (and VERY happy I am), I really like doing the exams with Mary on all the patients. I am learning so much! And I heard my first heart murmur.

After work, Mary the NP invited me to go to a pottery class with her (we bonded a little because we both love to do all sorts of art). So I went with her to Oak Ridge, which was about a 45 min drive through the hills, to this fantastic little art center. She let me glaze (paint) one of her pots and it will be fired in the kiln next week so I'll get to see how it turns out. The instructor was so friendly and he let me "throw a pot" on the wheel. Pottery is one of my favorite activities, but I don’t think I have done it in about 4 years. It was so great to get to do it again. I find it so relaxing and kind of meditative. My first attempt on the wheel flopped, literally. However my second attempt yielded a very cute little bowl. Nothing fancy, but just the right size for cereal :) The instructor, who is a phenomenal potter, invited me back in October to be an artist at their art center fundraiser where artists do pottery demonstrations. I vowed to him that when I get back up to Boston, I will get myself into a class. There is a great studio near where I live.

Tomorrow I am off from work because Mary doesn't work Fridays. Definitely going to sleep in. I want to get a tire for my bike because it has a big tear in it, and I might head back over to Oak Ridge to the American Museum of Science and Energy. During WW2, Oak Ridge played a big role in the Manhattan Project and the development of the atomic bomb. I don’t believe they are enriching Uranium anymore, but they are a big mecca for past and present scientific innovation. Sounds pretty cool--who would have thought that was in TN? Saturday I am going on a hike in the Smokys with a hiking club, and after that who knows?

Have a great weekend!

Today was great!

I saw 20 patients between 9am and 8pm (with 30 mins for lunch and 30 mins for dinner). The day really flew by. We saw only 6 pediatric patients and the rest were adults. Like yesterday, I went into all of the adult patient rooms with my NP Mary. She did the exam and if something was particularly interesting on exam I got to look/listen/feel too (i.e. felt 2! goiters, listened to many abnormal lung sounds, took a turn scraping out impacted earwax, etc). But for the pediatric patients, I went into the room alone, did an exam and then came out and presented the patient to Mary. Then we went in together and finished it off.

This is probably one of the most valuable things I will do as a nursing student. All day yesterday and part of today I watch her do exams and take histories. I've done modified ones on my patients in the hospital, and I've watched my pediatrician step-dad Walter do them on his patients in the past. But going in to a room having just had 30 seconds to glance at the patient's chart, today I gained an appreciation for their assessment skills. I'd come out the rooms and present to Mary and shed say..."well how many days was the fever...how many times did he have such and such...what meds is he taking...what color was the discharge, etc?" and often I would reply, I don’t know or I forgot to check that. So I'd have to go back in and check whatever I missed. Mary is very good at her job because she is thorough, but it is intimidating when I come out of the room and she fires questions at me.  As much as I hate being wrong and finding out how much I really don’t know, it is so helpful because I am learning from my mistakes rather than just being told what to do. I am learning quickly what questions to ask, and what not to forget to do. I am learning to think on my feet, and getting in the habit of asking myself "what am I missing?" before I walk out the door. Patients may come in for one thing, and end up with a completely unrelated but even more important diagnosis because the provider asked the right questions.

I think this is going to be so important because in school, we learn how to inspect, auscultate, percuss, and palpate, but we practice on each other. They don’t teach us how to do it if the patient is uncooperative, or has questions we weren't expecting to have to answer. In real life there are so many distractions. Learning how to do a thorough exam while attending to those distractions cannot be taught in the classroom.

Also, for the pedi patients, after the exam, I write a SOAP note on the patient, which Mary uses for the patient's record.  Soap stands for Subjective, Objective, Assessment, and Plan, and it is a way of organizing patient data into a note that is easy to read and sums up the visit clearly. We wrote them all year in nursing school, but none of us thought that they really used them in real life. It is nice to know that all that note-writing time in clinical wasn't for nothing! Thanks Emily and Nancy! (my clinical instructors)

So today's roll call:

-An older woman with high cholesterol (so many patients have it)
-A few people with pneumonia or other respiratory complaints
- A young woman who came in for fatigue, and ended up leaving with meds for a bladder infection and a massive infestation of pinworms (look it up, its nasty!), that she had had for 4 years and never sought treatment for. She either got them from her cats, or her cats got them from her. Not sure which. 
-Three people complaining of joint pain. One brought Mary the NP 3 dozen eggs from his farm (she gave a dozen to me)
-A woman with acid reflux
-Two people with hyperthyroidism and goiters (enlarged thyroid glands)
-A woman who requested hormone pills
-Kids with ear infections, stomach bugs, and one 2nd degree sunburn. One of the kids with a stomach bug was there with his 21-year-old mom and his four other brothers and sisters ages 2.5 months- 7 years old.

I also met the center's pediatric NP Sheila Moorehead today. She is fantastic! She grew up in South Boston but has lived in the south for most of her adult life. She frequently travels back up to Boston to help out at the MIT medical center and at Hanscom Air Force Base (2 of her former employers) when they need some extra hands. So she fluctuates between a thick Boston accent and a real southern drawl, depending on the topic. I liked her right away! She also spends some of her time at the REACHS Children's Center, which, as mentioned yesterday, is a healthcare and advocacy center for kids who have been abuse. She is a S.A.N.E. Nurse (Sexual Assault Nurse Examiner), so she is the one who does rape kits on the teens in the region and testifies in court on their behalves. She was telling me about the program there. As if sexual assault isn’t traumatic enough, the rape exam process can be extremely traumatic for a child (or any person). So the center coordinates the exam and interview in such a way that the child only has to be examined once and tell their story once. The need-to-know teem observes everything behind a one-way mirror so that the child is, in effect, giving the story to all those people at once, without ever feeling bullied or surrounded by too many unfamiliar adults. There obviously is no good situation when a child is abused, but the center is able to make it as tolerable as possible for the child. The next few Tuesdays, my NP is out of the office on vacation days, and so I am going to go with Sheila to the Children's Center. It may be difficult, but like everything I am doing down here, I think it is so important to be exposed to and understand what happens to the population a provider cares for.

Also, I have to do some sort of community service project before I leave. I am not sure yet what it will be, but childhood obesity here is a major problem. Tennessee is tied for second place for childhood overweight and obesity out of all the states. Suggestions are welcome!

So far, I haven't really met anyone outside of the health center. I am there from 9am-8pm Monday through Thursday. I am hoping to spend my long weekends traveling around the region and exploring the other major cities. There is a hiking club in the Smoky Mountains that offers free/open hiking trips, so I think I will go on one this Saturday. It is rated as easy for experienced hikers, and since I am not experienced, I think it will be just my speed! If anyone has some free time between now and mid-June, please come and spend a weekend with me!

Hope all are well!

Today was my first day at the REACHS (Regional Education and Community Health Services) Clinic. 

A little about REACHS: They run several organizations in the La Follette area, including:
-The health clinic
-The Children's Center, which is a child advocacy and educational program for kids who have been victims of physical and sexual abuse.
-The Clothes Closet- a donation-based center where people can get clothing free of charge as needed.
-The House of Hope- a domestic violence shelter for battered women and children (they also provide battered men with shelter outside of this facility)
-The Developmental Center- an educational, vocational and residential program for mentally retarded adults.
-Educational and parenting classes.
-Prison healthcare, staffed full-time by a Nurse (who I am living with) and part-time by one of the health center physicians.
-Community outreach in the schools 

About the Health Center:
There are 2 MDs, 1 DO (Doctor of Osteopathy) and 3 Family Nurse Practitioners.  Each provider has their own LPN who assists them with vital signs, room setup, shots, patient education, etc. Aside from primary care, the clinic also offers pulmonary rehab, a federally funded black lung program for current and retired coal miners, dental services, lab and x-ray services, drug screening, correctional health services, and others. They treat regardless of patient's ability to pay. They are "fortunate" enough to have a drug room frequently stocked with medication samples and equipment from drug company reps, who are there daily. 

I was amazed at how much free medication they are able to obtain, and how freely they give it out (when appropriate). Drugs like Boniva for bone density (endorsed by Sally Field) cost upwards of $60 per pill, and the center is able to give away several months’ worth to a patient. They even have expensive equipment they give for free like glucose meters, syringes, nebulizers, etc. The health center isn’t at all stingy with all of this stuff-- they are happy to give away as much as is needed. 

I don’t know why the drug companies give all of that stuff to the health center-- they must know they will not gain many customers. Most of the patients don’t have health insurance, so if they need meds, they fill their prescriptions at Wal-Mart, and get the generic for 4$ a round rather than 40$. Maybe the drug companies have a certain charity quota they have to fill each month. Who knows? 

The NP who I am working with for the month is Mary Morris, family NP. She's seems to be really good at her job, and seems to me just as knowledgeable as any primary care MD.  I think she is in her late 30s, from Tennessee, and graduated from an entry level masters program like the one I am in. Very nice southern gal who lives on a farm, but has also traveled the world and still spends time out of the south, unlike most people I have met so far. 

I am really excited about my role here-- which we figured out today. For her pediatric patients, I will go into the rooms first, do a history and exam, come out and present them to Mary, and then we will go back in together to finish the assessment and treat the patient. This is definitely more than I expected to be doing, but it hopefully will really strengthen my assessment skills. For the adult patients, I think I will still shadow her rather than do the full assessment on them. 

Today I went into all the rooms with her and observed the exam (and did some vital signs) We saw 22 patients. About half were pediatric and half adults. 

The first four were adults with diabetes including one who was really non-compliant with her treatment and so was told today that she would need to start insulin. Her A1C, which shows how well controlled her diabetes is, was 10.6 (normal is less than 7 in people with diabetes). She got really angry and said that she couldn’t afford it and didn’t know how to give injections or how to know when she needed it all. It took a while to calm her down and explain that they would give her a lot of education and help her until she felt that she understood how to do it all herself. One of the nurses worked with her for about an hour after that teaching her and she left feeling confident that she could control her disease. 

There was 1 adult with strep throat, 1 man with neck and back pain, a few patients who ran out of refills of their meds and wanted some samples and a refill, a man who had balls of wax the size of jelly beans in his ears who was complaining that he couldn't hear well, a bunch of people with uncontrolled blood pressure (on about 6 meds for it), and a handful of kids with gastritis (stomach bug) and seasonal allergies. One woman needed a pap smear, and I guy needed a prostate exam. 

There was a woman with horrible teeth who had a recurrent urinary tract infection. I got to look at her urine under the microscope, which was really interesting (I love microscopes). There were little bits of everything in it: red cells, white cells, loads of rod-shaped bacteria and little round bacteria all swimming around the slide. 

A 17-year-old came in with her mom for a pregnancy test. It of course was positive, which was no surprise to anyone besides the patient and her mom because she hadn't had her period in 2 months and she didn’t use any form of birth control. Her mom asked if it could be anything else. The nurse said no. 

What really struck me about this was how the conversation went:
Mary the NP: so you are pregnant, let me prescribe you some prenatal vitamins
Patient: I'm pregnant? (crying, not happy tears) 

There was no mention of any OPTIONS. Not adoption, not abortion, nothing. People don’t talk about it. If you get pregnant at 17, you have a baby at 17 and 9 months. I asked Mary about it...she said that they don’t discuss it for a few reasons: 1) they are a federally-funded clinic and they would lose their funding if they suggested abortion. 2) If the person wants an abortion, they will ask about it, and then the clinic can give them a phone number for a place in Knoxville (45 minutes away). 3) Most people don't do that in this part of the country...if you get pregnant, you have a baby. End of story. 

This made me really think about cultural competency. What else do I need to know about here? I asked Mary, along with the RN I am living with and they couldn’t think of anything offhand. But they also are from here and have worked here most of their lives, so I don’t know that they would be able to identify anything that was different. I will pay very close attention to this from now on.

Thanks for reading!

I am leaving tomorrow to go on a bit of a journey.

I am headed to La Follette, TN for a month to work in a community health clinic in a rural mining town.  I expect life to be so different there. The average household income there is $17,900. People have black lung disease because they work in a coal mine. Kids go to the doctor because they are very sick, not to get a physical to go to a fancy summer camp. 

I am in school to become a nurse practitioner. The role of a nurse practitioner in a primary care setting is like that of a doctor in that setting: assessment, diagnosis, and treatment of the patient's health or illness; but the NP has the benefit of spending more time than the MD and really getting to know the patient. We get to asses not only the physical state of our patient, but the mental and emotional wellness, and we intervene where needed. In addition to medical diagnoses like pneumonia and myocardial infarction, we use nursing diagnoses like ineffective coping and altered role performance. And we figure out how to fix it.

I always thought I would go into critical care or emergency care, but I now think that I will someday want to work with this population in an underserved setting.  I like the idea of working in a place where there limited resources and you have to be creative to make it work, but you also have to be so prepared and on top of things because there may be no one else around who can help.  And the end result is life and health and wellness.  know I will make mistakes and there will be times that I won't know how to help, but I can't wait to try. Working in a high tech environment like MGH or Children's, you have to understand technology and how to interpret results into a diagnosis, but in an underserved setting, it must come from a thorough history and exam.

I am really curious to see if any of my expectations are anywhere near right, and to see to see if I come home so excited to take on that role or if I will want nothing to do with it. Only time will tell. 

I am also psyched about my road trip.
1st- it is my first ever real road trip (I bought my first car ever.  I think her name is Smoky). 2nd I will be going to some really beautiful places.
Saturday- driving to Cherry Hill NJ to see my cousins and grandmother.
Sunday- Driving 7 hours, south through the Shenandoah Valley in Virginia- to hike and draw and see the beautiful mountains. Then saying over in Roanoke, VA 
Monday. Drive South again with a break in the Smoky Mountains and then on to La Follette, 45 minutes north of Knoxville.

I am required to keep a journal of my experiences, so I post to you.  Thanks for reading. 

Health and happiness to you all.