Tuesday, February 19, 2008

Clinical Journal Entry #4: 2/13/2008

Soooo late - soooo sorry! I had a really rough past few days, but last week's clinical experience was a great one, and it went a little something like this...

This week in clinical was my most fun experience so far. It was my turn to have an Alternate Experience day in the hospital's endoscopy center, so I spent the day helping with a total of 7 patients: 4 with colonoscopies, 1 with a bronchoscopy, 1 with both a colonoscopy and endoscopy (EGD), and 1 with an EGD with variceal banding.

I spent the day working with a team of two nurses and a doctor - one of the nurses being my 3-year-old Sunday School teacher at church! Although the procedures were all very organized and similar, the patients definitely made each experience very different.

For the most part, we would take a patient in, get a set of baseline vitals, give them a nasal cannula, and RN1 would administer around 50mg IVP of demerol (meperidine) and 4mg IVP of midozolam (versed), depending on if the doctor thought they needed more or not.

Once the patient was mildly sedated, Dr. would perform the procedure. RN1 and I monitored the vitals, and RN2 assisted the doctor with whatever tools he needed, as well as helping him adapt and maneuver the scopes. Over the course of the day, Dr. explored the GI tracts of half a dozen patients, cauterizing sigmoid polyps to destroy any remaining potentially-cancerous tissue, and removing and biopsying pre-cancerous polyps. He was a phenomenal teacher and was very friendly and respectful of me and his nurses. He made sure he explained to me every single thing we saw on the screen as we watched what the scope was passing by - all of the anatomical landmarks, all of the normal and abnormal tissues, etc. He explained etiology, treatment options, and all kinds of fascinating things.

I learned so much more from the colonoscopies and EGDs as well. Our male patients were pretty easy - they talked to us, maybe complained of a tiny bit of discomfort, but were overall fine. The females, on the other hand, were extremely difficult. Even our sweetest patients became hard to handle, and one even became a little combative. There was a lot of moaning and screaming, and it took three of us to hold one woman down. I wondered why the women were tougher cases, but Dr. and the nurses explained that they have their reproductive organs in the colon area, and women who have had abdominal surgery (such a c-sections) have scarring, and things are just kind of piled in there, so the intestines have far more sharp turns and twists than men. Thankfully, the procedures are only around 20-minutes long, and getting in is the hardest part - getting out is usually easier, so a bunch of hand holding and deep breathing comes in really helpful to get the patients through the most uncomfortable parts.

For the bronchoscopy, I took a break from RN1, RN2, and Dr. and joined 2 other RNs and a pulmonologist. They partially sedated the patient before inserting a bronchoscope into his nostril and taking it down his trachea and into his lungs, exploring his bronchi searching for blood clots. It was fascinating to see the inside of the lungs, and I was very happy that they were unable to find any blood clots.

Our last patient of the day was in for an EGD and esophageal banding. I found that very interesting. He had a case of liver disease caused by cryptogenic cirrhosis (cirrhosis without a known cause) although Dr. and other doctors now believe an obese lifestyle and/or type 2 diabetes is the cause behind it. Anyhow, when liver disease causes a buildup in scar tissue,the closing off of many of the liver's blood vessels (something called portal hypertension) occurs. The portal vein, being venus, carries impure blood back to the lungs to be cleaned. The liver processes liters of blood a day, but with portal hypertension, there is increased resistance due to the blockage of all of the scar tissue. As a result, the blood has to get out however it can, so it just pushes harder, and the pressure backs up through the portal vein which creates varices inside the esophagus and also the stomach. With all of the increased pressure, they have a risk of bursting and obviously bleeding, so it is necessary to perform endoscopies to check the size and amount of varices, and a banding attachment (invented by a doctor at Dr.'s med school overseas!) is used to obliterate the largest, riskiest varices. Basically, it opens wide, places a tiny rubber band around the base of the varice, and closes it so the band tightens and cuts off the blood flow. Within a few days, the varice just shrinks and falls off. Doctors used to just inject them with poison, but that is old technology, and now it's just the stubborn older doctors who use that method.

See, I learned so much this week. I learned if you don't ask questions, you won't know anything. The more you ask, the more you'll learn - especially with great nurses and a great doctor like I worked with that day. I loved having visuals to associate with the inner-workings of the human body, and I it really just helps clarify a lot of the body's physiology. Also, I learned a lot from the nurses - the role of the RN in endoscopy is to assist the doctor, monitor the patients vitals, administer anesthesia, comfort the patients, and definitely orchestrate the flow of the day. The nurses are really the backbone of the unit. I also noticed that especially in such a busy unit, it's absolutely imperative to be on your feet and observe everything that goes on. You never know when you could help another nurse or a doctor prevent an error that they may be too occupied with something else to see. Multi-tasking and just general acuity are key, and being on a unit that performs tests only, you definitely get a prime opportunity to hold a lot of scared hands.

My day in endo was a great learning experience I'll never forget.

I've really been dragging for the past week or so, and on days like today, if it weren't for my patients, I would have no reason to get out of bed.

Gotta. Keep. Going.

BUT... Can't wait for tomorrow. I hope I can muster up some hope to share.