MS Biology Program: Student Blogs

My time as a volunteer at UPMC has come to a close. These past three months in the Urology and Urgent Care Clinic have honestly flown by, and it seems like I had really just settled into these positions the past couple weeks. The experience gained, and relationships built have had a significant impact on my future career as a health care provider by giving me invaluable experience with both patients and staff, by broadening my knowledge of medical and administrative procedures, and by enabling me to learn more through outside research on the procedures witnessed. This internship has enabled me to accrue much needed patient contact hours that will strengthen my application to Physician Assistant programs, and has further reinforced my desire to join the healthcare field.

Much like shadowing, this volunteer experience has allowed me to get a better idea of how each member of the UPMC staff contributes to patient care and how each of their roles work together. Everyone from nursing assistants, to patient care technitians, health unit coordinators, nurses, physician assistents,  and physicians were all viewed working together to see patients through from admission to discharge. This experience has given me a unique viewpoint of our healthcare system, both the good and bad sides of it, and has put my own contribution to this field into better perspective. The importance of communication with fellow staff members, and with the patients has been a major point that I have taken note of throughout my time in the two units, and hopefully I will be able to put my knowledge of these challenge areas to use by learning from what I have witnessed and improving them as much as possible. While my time as a volunteer has come to an end, my patient care experience is only just beginning, I was recently accepted on as a nursing assistant on the Urology floors, and have begun my training program to become certified as one. This will allow me to gain an even more in depth, hands on patient care experience while expanding my knowledge on current hospital patient care. This blog and time spent with the staff at UPMC Shadyside has been an experience that has opened doors, gained knowledge, and help propel me on my path to PA school. It has been a pleasure documenting it all and I hope my readers have been as inspired reading about my time spent in these units as I have had working there.

This past shift at the Urology Center fell on the 4th of July which made for a relatively slow day. The two floor center only had one of the floors open, and only a handful of patients occupied this floor. While this made for a very relaxed day which only consisted of minor restocking and running errands for the patients, it afforded me more time to ask questions to the nursing staff and gain a better understanding of what it is like to be a patient in the center. A topic that came up that is an always present challenge for the staff is that of pain management. Any surgery, especially abdominal, can result in tremendous amounts of pain for the patient, and it is up to the anesthesiologist and support staff to regulate this pain.

Anesthesia, greek for ‘without sensation’, is a term used most commonly in conjunction with a pharmacology induced lack of pain, relaxation of the muscles, and a general amnesia. Anesthesia is used, locally, regionally, or generally, to knock out sensation and relieve pain to a part of, or entire body. The local and regional types of anesthesia don’t leave the patient in a completely unresponsive state of comma, and often times a patient can be put under what is known as procedural sedation and still be responsive to the physician, but still have no memory of the procedure. To be fully ‘put under’ for a major operation is a term that is referring to the use of general anesthesia.

This wide range of sedation from mild to coma like is accomplished by a combination of several drugs, administered at varying doses depending on weight, sex, metabolic rate, and other factors of the patient. The route of administration also varies depending on the drug and circumstance. Nitrous Oxide is often inhaled, whereas drugs such as ketamine, diazepam, fentanyl, or midazolam are more commonly given orally or injected intravenously. Drugs ending in -aine, such as lidocaine, novocaine, and even cocaine are (or were) milder anesthetics used for local anesthesia and are often given topically, injected, or even sprayed on.

Not surprisingly, the greater the amount of drugs given, and the more the patient is sedated, the greater the risk of complication. This is due to the fact that the drugs work on the central nervous system, inhibiting pain and memory, but also affecting breathing. Should a patient receive too much anesthesia, their blood oxygen levels could fall too low, they could slip into a deeper coma or even die. This is why when under general anesthesia, an anesthesiologist carefully monitors respiration rate, blood oxygen, pulse, and brain activity to help regulate the dose of medication and ensure a pain free, but safe experience.

When working on the Urology floors I come in contact with a wide range of different machinery and tools every day. The amount of technology present in each patient room is quite astonishing the first time seeing it, but I soon realized the necessity for each piece of equipment in every room. Each room has of course, a bed for the patient, which looks normal enough but is actually a fully electronically adjustable bed featuring many different positions and places to attach other equipment if needed. Mounted into the wall behind each bed is a large panel that is used to connect the iv pump, any suction pump used, oxygen, and all of the vital sign attachments and associated readout screen.

At first glance it was a bit intimidating, not knowing what each thing was, or how to connect/disconnect any of it, but through seeing each individual piece used at some point by the nursing staff and PCTs I am slowly getting to know the workings of the unit. While I have only hooked up some of the vital sign equipment such as blood pressure cuff and oxygen sensor, I have yet to set up any of the suction pump equipment, nor have I seen it set up. As a volunteer the single most important piece of equipment to know how to hook up and disconnect would be the I.V pump. While normally plugged into the wall, the unit can also operate on battery power allowing it to be disconnected for when the patient must move, or be moved. If a patient for instance is being transported from one unit to another, or simply to another room, the pump can be disconnected from the wall unit and transported along with the patient. Most common for me however is when I must get a patient ready for their walks down the hall, all I.V drips and other connected equipment must be attached to the pump, and then the pump disconnected so as to allow the patient to move about freely while still receiving any intravenous medication or nutrition. There are a variety of pumps available for use depending on the needs of the patient. There are automated pumps that will deliver a set dose of either medication or bolus of intravenous nutrition, at intermittent or continuous rates, as well as pumps that allow the patient to designate the delivery of their medication (most commonly for pain control). As with the I.V pump and other equipment, whatever the need there is a specifically designed tool to fit the job.

Due to the fact that the Urologic Care Center deals with all problems of the urinary system, it is apparent that one of the most common (and most frustrating) conditions to deal with is pain in the bladder, a symptom common of the condition interstitial cystitis. This is a very widespread syndrome present with many individuals and results in frequent but difficult urination, radiating pain from the pelvic area and in some cases blood in the urine. The reason it is such a frustrating condition to deal with is because of the widespread range and severity of the symptoms in each case, and finding the most effective way to treat each case. Each individual’s case must be treated based 0n that persons symptoms and any past measures taken to treat the condition, often times it is a mix of pharmacological, nutritional and behavioral steps that provide the best treatment.

While this condition rarely results in surgical intervention, in some severe cases, surgery is the best option and is why patients would end up in the Urology Center. The diagnosis of interstitial cystitis is often one of exclusion of other diseases, infections and syndromes being that there is no clear cut imaging technique of diagnosis procedure that will result in identifying this condition. It is the ambiguity of this syndrome that makes it so difficult to not only identify in the first place, but also to grade the severity of it. It is up to interpretation of the pain level and patients symptoms by the doctor to come up with the most effect pain and symptom management regiment. One of the more useful imaging techniques for understanding the severity of this syndrome is through the use of a cystoscope, which allows physicians to examine the inner lining of a patients bladder.

This allows the urologist to check for the presences of ulcerations and gain a better understanding of how bad the inflammation is. Much like the symptoms and treatment, the etiology of interstitial cystitis is also somewhat of a mystery. Many causes such as the presence of toxins in the urine, dysfunction or malformation of the cells in the lining of the bladder, autoimmune disorders, and/or infections may all contribute to this syndrome and proper identification of the cause will help specify a more  successful treatment. No matter what the etiology or symptoms, each case of interstitial cystitis that comes to the Urology Center is guaranteed to be unique.

One of the benefits of working at the Urgent Care Center is that it presents me with a wide range of conditions, injuries, and sicknesses to learn from. While there are certain cases that are more common than others (the flu, mild lacerations), sometimes more unique cases present themselves. This past week at the Urgent Care center at Shadeyside, a middle aged man came in complaining of a flushed face, itchiness, and hives, the suspected cause was an allergic reaction to his medication.

Drug allergies are a quite common occurrences, with allergies to penicillin being he most prevalent. These reactions take place under the same circumstances as any other allergy, when the body identifies the drug as a foreign substance and tries to expel it from the body by attacking it with histamine and other inflammatory agents. This widespread mobilization of white blood cells and their resulting attack on the presence of the drug causes the symptoms felt by an allergy attack such as the itchy skin, redness and hives, congestion, and swelling. In more severe cases this swelling can cause life threatening symptoms such as difficulty breathing and even death. Treatment for more mild reactions to medication often consist of treating the symptoms and reducing any swelling (most commonly with antihistamines and corticosteroids). Depending on the drug prescribed, there may be a less allergenic alternative available. In severe cases of allergic reactions however, sometimes epinephrine must be administered to reopen airways. Unfortunately there is no surefire way to know if someone will have an allergic reaction to some medication, it is up to the physician to look into the patients history and come up with the medication which best suits their condition as well as poses the least likely chance of causing any damage.

This chart explains the different types of allergic (or hypersensitive) reaction. A drug reaction would fall under Type 2

This week on the Urology floors provided me with a unique experience in that I was able to shadow one of the patient care technicians (PCT) for some of the night while rounding on patients. PCTs make up a large portion of the workforce in both patient floors and the emergency department. They are responsible for the majority of the patients needs including regularly monitoring vitals, moving the patients, taking blood samples, getting food drink or other necessities, and communicating any change in condition to the physician or nurse. Most PCTs complete some kind of training course such as one to become a Certified Nurses Assistant, are previously EMTs or Paramedics, or have first aid, CPR and some kind of in house training course to prepare them for their duties.

During the time I spent with the PCT, we rounded on several patients in the urology center, all of whom were overnight patients. Most visits were fairly routine and consisted of checking to see if there was any change in their condition or vitals, see if they needed anything, checking on any wounds or incision areas or administering special therapeutic bandages. One of the patients had been in for surgery earlier that day, and needed to be brought up out of bed and taken for a walk. Many patients who have some sort of abdominal surgery, or even an adverse reaction to medication can develop painful gas bubbles and pressure in their GI tract. The easiest way to remedy this pain is to the the patient up and moving, so as to naturally alleviate the gas. For someone who has just gone through surgery however, this act can be a daunting one. First the patients IV pump must be disconnected  from the wall, and all medication and drip bags must be put onto the movable stand. Of course all vital monitors bandages and straps must be removed and the bed must be situated in an upright position so as to allow the patient to easily get out of bed. Special care was taken from the PCT so that the patient would use as few abdominal muscles as possible and not strain their point of surgery while exiting the bed. From that point we positioned ourselves on either side of the patient as he made his way down the hallway, to provide any balance support if needed. After having completed his walk, we returned the patient to his bed and reattached all necessary equipment. After this the PCT was on to the next room to check on the rest of her assigned patients. This experience has given me an insight into how much of the care is done by staff other than nurses or physicians, and how crucial the role of the PCT is to not only the urology center, but the healthcare field as a whole.

Cancer. One of the most frightening words for anyone receiving a diagnosis. While post-diagnosis longevity has slowly been on the rise and treatment for this disease is the best it has ever been, there still is no cure and it is often terminal. In the urology center, the most common type of cancer dealt with is bladder cancer, and luckily, it is one of the easier to treat. Like cancers in other areas of the body, bladder cancer involved the unregulated growth of abnormal cells and in some instances can become invasive and spread to other organs and areas of the body. Most commonly, this type of cancer begins on the lining of the bladder wall, and if it progresses can spread to the inner lining and supporting musculature. The type of treatment will depend on the stage and location of any tumors present, but restricted to the lining of the bladder, these tumors can be removed via surgery with good results. Due to the high risk of recurrence, treatment is often a multi-step approach including radiation and/or chemotherapy.

Most patients who are being treated for bladder cancer are first flagged in the emergency room, urgent care center, or an outpatient clinic with common symptoms such as blood in the urine, pain while urinating, and radiating pain felt in the back or abdomen. Once cancer is suspected, the individual would be put through a series of others tests to refine the possibilities for the symptoms. A pelvic (or prostate for male) exam, cytoscopy, urinalysis, CT and MRI are all possible techniques for identifying and accurately staging cancer. The function of other near by organs will be assessed as well testing nearby lymph nodes to see if the cancer has become invasive and spread elsewhere.  Depending on the type, location and severity of the cancer, different methods of surgical removal can be used. A transurethral resection can be preformed by using surgical tools inserted up through the urethra to remove any tumors. A cystectomy can be done in more severe cases in which part of or all of the bladder and associated components are removed. In cases such as this, the use of a urinary drainage bag attached via a catheter must be used in conjunction with rerouting of the urinary passage from the kidneys.

A urinary catheter is a common tool used in many different cases in which a patient is unable to urinate normally such as urinary incontinence, urinary retention, or surgery of part of the urinary system. It is a tube like structure that is used to create an opening and regulate the exchange of gases, fluids, or even solids.

This last week at the Urgent Care Center presented me with the new responsibility of conducting the ‘patient call backs’ for the clinic. This involves calling patients who were in for a visit (for procedures/visits other than vaccinations and bandage removal) and seeing if they have any questions, comments or complaints about their visit. The comment is taken down and then passed along to the appropriate staff member who treated the patient/was involved in the comment. All of the patients who are to be called are in a large book containing the date of their visit and basic information regarding their visit. This allowed me to get a general idea of what kinds of treatments/procedures are most common for the clinic. The most common reasons for visit were things such as cuts, possible broken bones or sprains, unknown rash/infection, and sickness.

The following are the approximate steps that a patient would go through for the treatment of a broken arm.

Broken arm – The treatment for this type of injury is completely dependent on the type of break. Different types include compound, closed, greenstick, and comminuted. Most likely a patient with a more serious break (compound/comminuted) would go straight to the emergency department, but a patient with a smaller stress or closed fracture may not be sure of whether or not they have a broken bone, and thus come to the clinic. After first doing a basic physical and history data collection, the physician would physically inspect the area of fracture, and may manipulate the area to get an idea of how severe the break is and if any other surrounding tissue has been damaged such as nerves or blood vessels. The x ray is the imaging technique most commonly used to view any possible bone fractures, but may be backed up by CT or an MRI scan to further assess a possible break. The best way to treat a broken bone is to immobilize it (realign if necessary) and allow it to heal without further stress placed on it. Splints, slings, plates and casts are the most common methods of bone immobilization, and are dependent on the severity and location of the fracture. After a predetermined amount of healing time, the patient will undergo a follow up visit to assess how the healing process is coming along, and if further support for the bone is needed.

(http://www.affordablerx.com/images/illustrations/typical_fractures.jpg)

Having now established myself into my positions at both the Urgent Care Center and the Urology center, the start of each work day is quite routine and involves getting the most pressing chores done. While these are the same duties week to week, they are my primary responsibility while on the floors and must be completed to best aid the nurses and staff. After general restocking, disposing of materials, and doing an initial round on all the patients I am able to ask the nurses specific questions about the patients currently held on the floor, or any extra ordinary case they had that week. Each week here out I will focus my blog on a new procedure in order to broaden my knowledge on some of the operations and procedures commonly done at both the Urology Center and Urgent Care Clinic.

Laparoscopic Appendectomy

This week I was talking with a patient who was in for the removal of her appendix, or an appendectomy. This relatively common procedure for the Urology Center and normally only requires a one to two day stay if no other complications arise. The individual I had talked with had the surgery performed that morning, and was on schedule to be discharged the following morning. An appendectomy is most commonly done to remove an inflamed appendix, a condition known as appendicitis, which can be caused by a bacteria triggered inflammatory response often resulting from the blockage of the appendix opening. For whatever the root cause, an inflamed appendix can be extremely painful, cause fever, swelling of the abdomen, nausea, and may even rupture, causing infection, sepsis, or even death if not treated. However most cases are caught before more life threatening conditions develop. However routine the procedure, there is still a lot of preparation that must be done in order to prepare the patient for the operation. After positively diagnosing the condition through symptoms, white blood cell count, urinalysis, or some kind of imaging technique, the patient is started on a regiment of antibiotics up until the time of the surgery. Laparoscopic surgery is the more common, and least invasive method available today, and involves cutting small incisions into the abdomen of the patient in order to feed through a laparoscope to identify the inflamed appendix, and small surgical tools to remove it. This method doesn’t require as large incisions as the traditional method, results in smaller scars, and a faster recovery period with less pain. In cases where it is not known if the patient has appendicitis, this method enables the surgeon to physically view the appendix without performing an extremely invasive procedure.

(http://upload.wikimedia.org/wikipedia/commons/c/c3/Laparoscopic_stomach_surgery.jpg)

(http://www.jeffersonhospital.org/images/staywell/125534.GIF)

After having the first week to get accustomed to the two new locations, the second week of work enabled me to jump right into my duties without having to get used to my new surroundings. While having introduced myself to the majority of the nursing and hosting staff for the Urology floors the previous week, I was able to quickly ask what needed to be done when I first got there. Due to a build-up in the needle bins and a depletion of many of the utility bins throughout the floors, the first hour and a half was spent restocking and cleaning out the various bins and holsters. Later on in the night one of the nurses took me along and showed how to prep a room for housing a patient going into surgery the next day. Everything from the stretcher that would carry the patient, to the oxygen and I.V pump had to be specially prepared so the physicians could get right to work without any delays the next morning. The clothing, blankets, oxygen, and tubing the patient would be utilizing had to be prepared and layed out, along with a specialized medical cart that carried the needed anesthesia and meds for the patient before and after the surgery. The experience certainly gave me a better appreciation for all the work that goes in before the actual surgery that both the patient and even the surgeon never see. It also served to show how efficiently this department is run. With a smaller overall staff size than the emergency department, it seems as though each member must stay busy to accomplish all that needs to be done to keep things running smoothly. The fact that the majority of the staff is very experienced adds to the efficiency of the whole operation.

Another new experience from this week was encountering a patient who had neutropenia, which is a disorder affecting a specific type of white blood cells called neutrophils. Patients with this disorder are much more susceptible to bacterial infection and special precaution must be taken to avoid any exposure to possible threats. This patient had a sign posted on their door, and required any staff/visitors to wear gloves, a mask, and a gown all to limit possible contact between the patient and any outside pathogen/bacteria.

The Urgent Care Center was much busier than the previous week, which made me thankful to have a day to get used to my different responsibilities before I had to work at a much faster pace. While this week still only consisted of answering the phone and taking messages, collecting patient I.D and insurance information, and recording the ticketed parking positions, the volume of patients made the pace of work much more intense. Due to the busy nature of most of my shift, I was unable to visit the back section and view any procedures/talk with the staff, which is a future goal of my stay here.