Charting

I should be doing some actual charting – well fake charting anyway (I’m supposed to write up a note for one patient and come up with a differential diagnosis for another as practice before Friday) – but I didn’t want to forget some of the things I learned and felt on my first day of clinical as a student midwife:

1) Vitals are vitally important to me.  There were a lot of differences between clinical today and clinical last year.  Last year I spent my whole day with one, maybe two patients.  I did my shift in a hospital wearing scrubs.  Today, I saw five or six patients in an out-patient clinic wearing “business casual” attire.  Perhaps the smallest, yet biggest difference was that I didn’t take one set of vitals today, whereas last year I would have taken at least two sets in the same amount of time.  Usually, it was the very first thing I did with a patient.  I hadn’t realized how much I relied on that ritual – walking in, introducing myself, taking a set of vitals.  Not only did it give me a basic and general picture of how my patient was doing, it was a way of breaking the ice, an acceptable and non-threatening way to begin to touch and care for them.  Plus, it was something I felt comfortable doing and knew I could do well.  Today, I observed my preceptor for the first two clients and it wasn’t until she shooed me off into a room by myself that I realized that I wasn’t entirely sure how to begin a conversation, how to begin providing care without using vitals as a bridge.  I faltered initially and eventually found my way.  It wasn’t difficult to quickly develop a new way of interacting with clients, but a part of me was sad to realize that it’s no longer really my job to take vitals and that depending on where I work, I may never have to do them again.

2) I have GOT to learn how to use a plastic speculum.  This doesn’t really need explaining.  I learned and practiced using a metal one.  Today I used a plastic one for the first time.  Let’s just say it could have gone better.

3) Out-patient visits are like snowboarding.  My best run of the day is always the one right before lunch.  After lunch I start getting sloppy and fall more often.  That’s kind of how today went.  I was feeling pretty proud of myself after my last patient before lunch.  I  correctly measured her fundal height, correctly picked up the fetal heart tones on the doppler, correctly figured out where her baby’s head and back were, had a nice conversation with her regarding her concerns about labor and came up with the same diagnosis for her cough as my preceptor (GERD-related).  After lunch was when the specula debacles occurred, and also when I started getting sloppy while taking my histories.

4) Life has a way of maintaining equilibrium.  I decided to go outside for a bit of a walk during lunch.  I was in a good mood because of that last patient and feeling positively about my skill set and knowledge.  Then I ran into a woman on the street, who was clearly distressed and who only spoke Spanish.  She said something about “emergencia,” and, since she looked upset, but not particularly sick, I thought that maybe some emergency had happened to a loved one and she was lost.  Not knowing the word for hospital in Spanish, I asked her, idiotically, in Italian, “hospidale?”  As it turns out the Spanish word for hospital is the same as it is in English =P.  She said that yes, she needed to go to the hospital and so I told her to follow me as I was walking to the main entrance.  As we were walking, I noticed that she was very short of breath and, growing concerned that perhaps the distress I noted earlier was not because she was lost, but because she was having some sort episode herself, I asked, “familia?”  She replied, “No, me.”  She was breathing pretty hard at this point so I stopped and said, “dolor?” She said “no, la presion alta.”  This was enough of a cognate for me to know that she had high pressure, but since my post-lunch-run syndrome seemed to be setting in early, I decided she meant that she was short of breath because of some sort of high pressure system.  Due to the weather? (Even though I knew that we’re actually in a low pressure system right now, but hey, I was panicking.)  The fact that we were on a hill? (It did cross my mind that pressure and altitude are not the same thing AND that CT is essentially at sea level, but again, panicking.)  At any rate, I did get it together enough to realize that when she had said “emergencia” earlier, she meant that she needed to go to the ER, so I walked with her there.  After I deposited her safely into someone else’s more capable hands, I reflected that life had a funny way of providing you with moments that remind you of how good you are at some things, and how bad you are at others.

5) I am the bottom line.  I was auscultating the heart of one of my patients today and I heard an abnormal sound over her mitral valve.  I couldn’t tell exactly what it was because it was irregular and I wasn’t in the best position.  I thought it might be a gallop, but I tried to say “Tennessee” and “Kentucky” as I listened and it just didn’t fit.  I knew other ways to differentiate and assess, but I felt bad that I was already taking so long and so I walked out to find my preceptor.  My preceptor used those techniques that I knew I should have used and determined that it was an occasional split S2 (totally benign, but also weird that I heard it down at the mitral valve and not up at the pulmonic).  Last year, my physical assessment was more of an academic exercise.  Someone had already done a thorough exam and charted it and typically I was comparing my findings with the chart.  If I messed up or missed something, it was no big deal.  My findings never went in the chart and someone (usually multiple someones) was always checking my work.  Now my findings do go in the chart.  My preceptor is still there to double check me, but since this is a primary care setting, I don’t have someone else’s answers to compare to and fall back on.  I’m the person most likely to find something that may need to be explored further.  It’s a lot of responsibility and a good lesson to learn.  I’m just glad I learned it with a split S2 and not a mass in someone’s breast.

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