My third rotation was held at New York Presbyterian Queens for Internal Medicine, a site which I hope to return to. I overall had a wonderful learning experience at NYPQ and the staff in general were just so helpful and nice. This is a place that I can see myself working in the future if given the opportunity to. My rotation consisted of being assigned to different sub-sections of internal medicine, including stroke, heme/oncology, pulmonary, cardiology, and ICU. I learned so much from all these specialties, more than any other rotation that I have had. I will be discussing my experience at NYPQ in detail in the reflection below.

My first week in NYPQ was spent on the stroke team. To be honest, I think I enjoyed the stroke team more than most people and I think the reason behind this is because I got to follow the patient from the moment they stepped into the hospital doors, until they were well enough to be discharged. At NYPQ, there is a stroke call on the overhead, that informs the stroke team that there is a patient that might be illegible for tPA or MISTIE for intracranial hemorrhage. Because tPA and craniotomy is time sensitive, it is very important that the PA in charge of stroke recognizes the stroke as soon as possible and takes affirmative action to prevent any further damage. It was very fast pace in the beginning, where the patient needed blood drawn right away and was immediately transferred to CT imaging of the head to rule out hemorrhage. If the patient was eligible for tPA, measures were taken promptly in order to the tPA to be pushed on time, and in order for this event to occur in a smooth manner, there needed to be intrapersonal communication and teamwork. Everyone worked harmoniously during a time of urgency and it was really nice to watch how the staff really pushed their differences a side in order to help the patient.

In terms of recognizing a stroke, I believe I am much more comfortable than when I first started. I believe I have seen enough stroke cases that I can comfortably identify a patient who is having an active stroke. With that being said, there are still some patients that come to the emergency room with very atypical symptoms and even for the attending that is a little hesitant in admitting as a stroke patient. I guess there will always be outliers in the population and it will take many years of experience for me to become comfortable with those presentations. One of the biggest surprises that occurred to me while I was on stroke was that there are a lot of patients that are not eligible for tPA. For a majority of these patients, they were ineligible because they missed their time window of receiving tPA, which begs the question of why the population is not informed enough to know when to bring someone who might be having such symptoms to the emergency room quicker. Family members knew exactly when the patient started the symptoms and they were very supportive in terms of being there for the patient, but they just did not know if they were supposed to bring the patient to the hospital when they first started the symptoms. I think this experience has made me more passionate about informing the public about early stroke signs and what should be done if the patient is experiencing them.

I think what I had the most difficulty when it came to patients having stroke was the NIH score. On the first day of the rotation, I had to complete this online NIH stroke scale course, so I would be able to assess patients that were having strokes. That course was actually pretty difficult because the patients would have such minor differences and I think I would want the patient to have a better score, which made my scoring bias. I also had a very difficult time assess patients with their peripheral visions. This might be because the patient is tempted to look my fingers when I would ask them to tell me “How many fingers am I holding up?” or again, it might just be my bias, wanting the patient to score a higher score. It was also very difficult for me to score patients when they were aphasic or not responding to my questions or demands. It was frustrating because there were quite a few patients that I encountered that did not respond to anything I was saying, and there is no section in the NIH scale where it kind of bulks unresponsive patients together. It was obviously a personal issue I was having because none of the other PA’s were having this frustration that I was having at the time of examination. I think in order for me to overcome this frustration, I need to practice with more patients until I know what to record as a score. I think I grew tremendously in terms of being comfortable in stroke, I remember the first patient I saw, I did not think the patient was having a stroke at all, but at the end of the week, I knew that I was wrong and I knew why I was wrong. I think the specialty of stroke might be a potential future for me, considering how closely the patient is monitored by the PA’s at all times.

I had the experience of being a student in the critical care unit, and in simple terms, it was terrifying. It was an amazing place to learn and even though it was only my third rotation, and I am still considered pretty unexperienced, I feel like I can say with confidence that the CCU is the place of real medicine. If a student is able to understand what is going on in CCU, that student is very well off when it comes to medicine. It was just so much medicine at once, it was very overwhelming for me, especially because I have almost zero background experience when it comes to medicine. Even though I would eventually catch onto what was going on, it was super hard to keep up with rounds just because the attending would take everything into consideration, as he should. It was really hard for me to keep up with everyone and everything, but I learned so much. The people in the CCU were so nice to me and so welcoming, which was honestly something that I did not expect in the CCU, considering how sick the patients were, I figured everyone would be super stressed and serious all the time, but they were the exact opposite. The CCU was also where I got to assist in placing a femoral arterial line, which was an awesome experience. I wish I had studied more before going into CCU because nothing that I had encountered was completely knew to me, everything that was mentioned in CCU was something that was studied in the didactic year. Just knowing a little bit more about the topics would have helped me tremendously when it came to rounds and understanding what is going on. To be honest, I hope that I will be skilled enough to work in the CCU one day, where I will be able to put all aspects of medicine together and come up with the best patient care plan.

My final destination was being on the hematology and oncology floor, where I got to perform a variety of procedures and got to know many of the patients that were assigned to my preceptor and I. The difference in this shift versus the others was that it was a night shift, so making that switch from day to night was actually not as bad as I thought it would be, however, making the switch back to days, was horrible. The people over the night shift were also very friendly, where everyone was just a big family that tried to help each other out as much as they could. My preceptor that I was assigned to overnight was extremely helpful in getting procedures for me. He would call every PA that was on the night shift and would ask them if they had anything that I could help with. This was the time I performed my first successful arterial blood gas, and to be honest, I faked it till I maked it. It was true that I had performed arterial blood gas before, but I was unsuccessful because the patient’s artery was difficult to nick, and I know it was not just me, but the PA that I was following, also had a difficult time. So when I was asked if I had performed an ABG before, I had said, yes, because technically I had. With this in mind, when I went to perform an ABG on a patient, I was much more confident and was successful in my attempt. After that experience, I was much more comfortable performing ABG’s. One of the skills I have yet to have mastered is venous blood draws. According to almost everyone that I have followed, VBG’s could be a hit or miss. Sometimes you get a patient with very good veins and sometimes you get a patient with very bad veins. My preceptor told me that the key to a good VBG is feeling for the venous pulse. Feeling for this pulse would really help guide where I should be sticking my needle, and he was right. Even though I did not do as many successful VBG’s as I would have liked to, one of the things that I did learn form this experience is that I should never be in a rush, or should never be intimidated by the amount of time I am taking to perform a blood draw. In my head, I keep thinking that “how could I screw up something so simple”, and because of this thought, anxiety would build up, deterring my performance. I learned that I should take my time with VBG’s, it’s not like the patient is going anywhere and this is my time to learn, so I should take my time, and find the best vein, and palpate for the best pulse and so on. I loved working at night, and to be honest, would prefer it over the day shift when the time comes. It was a lot more personal when it came to patients, there was time to sit down and explain certain things to family members that might have not been explained to them during the day, and overall, I really enjoyed it.

NYPQ for my third rotation was an amazing and unforgettable experience. I wish I would have had this rotation later on so I would have been a little bit more prepared for it, but I am glad that I experienced it. This is definitely a place where students should be sent to for learning purposes and hands on training for the PA profession. I hope in the near future that I am able to work at NYPQ because of the family like environment that was there at the time of my presence.

This entry is licensed under a Creative Commons CC0 1.0 Universal Public Domain Dedication license.