I rotated at Margaret Tietz Nursing and Rehabilitation Facility and generally had a great experience overall working with the elderly. One of the reasons for this is because a lot of elderly have many diseases, and because of this, I was exposed to clinical signs of diseases that we had learned about in the didactic year. Putting a face to the disease and treatment plans optimized my memory of the textbook understanding of the condition.  Even though Long Term Care is not somewhere I would like to work in the future, I think it is an excellent place to gain experience because patients have  multiple comorbidities and as someone that was not exposed to the healthcare field as much, I thought it was a great learning experience and I valued my time at Margaret Tietz. 

One of my biggest mistakes starting off with Margaret Tietz was being shy and underconfident for the first two weeks. It might have been due to the fact that it was my first rotation, and I did not want to mess-up or cause any problems to anyone else, so I tried to stay out of the way. However, this was not a smart move because I feel like the impression that I gave was that I did not want to do anything, which was the exact opposite of what I actually wanted. Honestly, it was a little intimidating because I felt as if the CNA’s were looking at me as if I was a snob, which is understandable, because they did not really know me. But I guess, when I was able to break out of my shell, I spoke to them and joked with them and eventually they liked me. One of the biggest advantages to this was that I got more patient experience out of it, if there was something that the CAN’s wanted me to see, they would call for me right away because they know that I would have been interested. The regret that stayed with me, however, was that I did not open up with the faculty sooner, and that is something that I will make sure I do not do on my future rotations.

In terms of H&P’s, I honestly had a very difficult time adjusting my writing styles to a nursing home facility that accepts patients from hospitals. One of my biggest issues were documenting previous hospital findings. In didactic year, when we practiced writing up H&P’s, usually, we did not have access to the patient’s charts, so we did not know any previous medical history, unless the patient was very competent and remembered everything that happened to them. In didactic year, our H&P’s were solely based off of the patient and their medical experiences. Taking that experience and applying it to Long Term Care, I was criticized by my preceptor because I failed to include findings (positive or negative) in my HPI that, I perceived as irrelevant because of the way the patient was presenting but were important in terms of Long Term Care. For example, an 82F presented to the nursing care facility s/p pancreatitis, treatment with supportive care. In the hospital, they did several imaging’s on this patient, and at first I did not include these imaging’s because the diagnosis was already established, I did not see the point in including specific findings in the HPI, however I was wrong and I fixed that mistake. Something else that I also forgot to add in the HPI were incidental abnormal findings, which were completely unrelated to the chief complaint. For example, this same patient was found to have a left breast mass that needed further workup outpatient. Even though this finding is completely irrelevant to the patient’s condition, my preceptor wanted me to include that in the HPI because it needs to be addressed in the nursing home facility, in which an appointment for a mammogram needed to be made. Even though this was a minor adjustment to the way I write-up my H&P’s, I still wish I was exposed to writing an H&P based off of previous medical records. I eventually became better at writing H&P’s to the point where my preceptor felt as if she could trust me to write one without her looking too deeply into it.

One of my goals for this rotation was to perfect IV’s. I miserably failed in my goal, let me explain why. A lot of elderly do not have “good” veins, but that should not really be an excuse. The first person that I ever tried to put an IV in, he was very old, dying with stage 4 gastric cancer. Before starting the procedure, I already had guilt in the back of my head, thinking that I am going to stab a man that is already in so much pain. When trying to look for a vein, I was just trying to look for a blue line, and I saw many, but the nurse did not really explain why they were “bad” ones, but finally, when I did find a good vein, I got a flashback, and when I inserted the saline flush, the poor man’s hand bruised up because I puncture through the vein without knowing. The site terrified me, knowing that I had done that, and I am pretty sure the nurse did not want me to try again. To be fair, the nurse that I was with was also unable to find a good vein, so they called in a much more experienced nurse who got the job done. A lot of the patient’s that I encountered had “bad veins”, and eventually, had a PEC line placed. I would have participated in the PEC line placement, but the facility did not perform them, they called specialist that performed PEC lines in the middle of the night. However, I have became more aware of what a “good vein” looks like and what we should be looking for in a vein that we would like to puncture. First off, a vein should be vertical. We would only use a horizontal if a vertical vein would not be present at all. Another factor to look for is pulsation. If a vein is pulsating, it will probably be a good vein to place an IV in. I probably tried to puncture 10 patients, and failed in all of them, however, the nurses that I was with also failed like 8/10 times, so in general, I just think it was difficult to place an IV in patients that have collapsing veins. Overall, I hope that my next rotation will involve many IV placements and I hope I get the chance to experience placing them.

Overall, the elderly population loved me. I’m not trying to be cocky or overconfident, but I received a lot of positive feedback from the elderly when they found out it was my last week. One of the reasons why I think that the elderly liked me was because I gave them my time, which I assume a lot of practitioners are unable to do, due to patient volume. I learned that the elderly are underestimated in their intelligence, and when they see someone that at least present’s as if they care about their concerns, they really do appreciate it. Just spending a few extra minutes with the patient makes a huge difference in how they see you and it also develops a better rapport. With that being said, not all patients are alike, there were a few, out of the many patient’s I saw that were kind of nasty to me, but it was not their fault.  For example, there was a patient that was sent to the nursing care facility and he had a known history of bipolar disorder. When I was asking questions about his health, he was very annoyed at me because he thought I was repeating the same questions over and over, but that was not the case. The main issue started when I was examining the patient and I noticed that one of his finger nails were completely missing, and so I asked him “What happened?”, and his response was very mean, using inappropriate language with me. I guess I could have asked the question in my more sensitive way, for example, “I noticed you do not have a nail on this finger, has it always been like this?”, because eventually, the patient told me that he was cutting his nails and it came off. Due to his vulgar language towards me, I did not feel safe completing the physical exam, so I asked my preceptor to complete it when she had the chance. What I learned from this situation was that I should be more sensitive towards patients and the way I speak to them, because they might be insecure about something, and depending on the way someone questions them about it, could trigger them to act out.

I had a great experience at Margaret Tietz and working with the elderly. Honestly, before beginning my rotation, I thought I would not enjoy it at all, but I was definitely wrong, I actually the elderly are just as cute as babies and show much appreciation for minor services. The only reason why I think I don’t see a future in Long Term Care is because of my personality type of “finding the problem and fixing it”. Unfortunately, what is seen in Long Term Care are patients with terminal illnesses and my instinct is to treat them, but that is not always the case in LTC. For example, there was a 97M who was generally in good health, that had very elevated PSA levels. Automatically, I thought this patient needs to be further worked-up for prostate cancer, but when I discussed it with the Doctor, she explained that because he is so old, and very functional at this point in his life, he is most likely going to die of something else, which is understandable, but the thought of this patient having cancer and not being treated for it, bothers me. Other than that, elderly patients are great and very wise. They love it when someone takes the time to listen to their complaints and empathizes with their pain. I am looking forward to my next rotation, which is pediatrics, the complete opposite of Long Term Care.

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