The halfway point: new thoughts and welcomed changes

As I finish my halfway point here at Palmer West, I have certainly gone through ebbs and flows. This includes my general energy state, my view on chiropractic philosophy, and my forecast for my near future. Some quarters I have been full of energy and enthusiasm, while others I’ve struggled to keep my energy high under the weight of the program.

My overall view on philosophy of chiropractic has also changed throughout my time here at Palmer. As I think of my future practice, I am searching for ways to take care of patients that fit with my philosophy and the philosophy of chiropractic that I have found in my time here so far. This doesn’t mean my thinking won’t change over the next year and a half, and I truly welcome the change.

-Damir Simunac, West Campus

Precepting – interning with a doctor

Oh … precepting.

Precepting is very similar to an internship at other colleges. During your last trimester at Palmer, you get the opportunity to go into an office and work under the doctor.

The regulations for each state determine what you are able to do while at the office. The doctors do not have to pay the interns, unless they choose. Each state has different requirements needed, if you can even precept with the doctor you want to. It can be difficult to find an office to precept with that you mesh well with and feel like you can spend 20 hours a week with. My deadline is quickly approaching and I haven’t found one that qualifies yet. I have found a few that would be fun, but don’t meet the Iowa qualifications.

-Christa Scheffler

Thanksgiving post

It was a short week due to the Thanksgiving break but quite busy.  I attempted to cross the hurdle of having a discussion with a patient about his weight and low back pain.  It was a new patient, so I was able to do the evaluation in “my office” without supervision.  Dr. Pavalock was busy working on something in his office and Abbey had a ton of paperwork to catch up on.  I was able to talk with the patient about the impact of being overweight on the biomechanics of the spine and how that contributes to low back pain/disc degeneration and the talk went pretty well…if you ignore the fact that the patient was face down on the table and I was palpating his back at the time, hahaha-sheesh.  One small step I suppose.  I’ll get over my hesitance soon.

The interesting case of the week was a patient with Superior Semicircular Canal Dehiscence (SSCD), a condition in which a small portion of bone (usually 1-5 mm) is missing from the skull in the inner ear area.  Symptoms can include but are not limited to dizziness, hearing loss and nystagmus. This patient has had surgery to plug the hole which resolved the constant dizziness but since then they have relapsed. The patient states that they knew exactly when the plug fell out as the dizziness returned immediately and has been constant since. The patient is scheduled for a new surgery consult to re-plug the hole.  Otherwise they are in good health and came by for a “tune up”. We adjusted the patient with no effect on the dizziness but it was an interesting condition to hear about.  For further information on SSCD click on: http://otosurgery.org/sscd_definition.htm

On Tuesday Dr. P, Abbey, and I were all invited up to the Post Deployment Clinic’s thanksgiving potluck which was very delicious and it was fun to meet the various nurses, doctors, and receptionists that work there; two of which have come down and visited us in our clinic a few times previously.

Wednesday through Sunday, I was in South Carolina visiting family. While I was there we watched Breaking Dawn part 1 in the theater…yup, I’m a “twi-hard.” Go Team Edward!  We walked around downtown Charleston and experienced the market there, somewhat like the Seattle fish market.  It was full of amazing arts, crafts, food, and pictures.  I went on my first ever plantation tour of the Magnolia plantation, which is world renowned for its garden, very beautiful.  We also went on a horse-drawn carriage tour of downtown Charleston and learned about the history of the city from being founded through the revolutionary and civil wars.  It was a fun and informative tour and Charleston is a beautiful city.  I was very thankful to spend the holiday with family.

Now a new week begins.  Thanks for reading and I’ll write again soon. 🙂

Alicia Ruiz, 10th Trimester Student
Davenport Campus

Now that’s more like it…

This week went much better than last week.  I am finally getting my adjusting skills closer to par for Dr. Pavalok and I was more successful this week with my adjustments, woohoo!

Dr. P has started allowing me to perform new patient physicals by myself in my office which is EXCITING!  They have been going quite smoothly, except for one in which I needed to have a frank conversation with a patient about the patient’s obesity and how it is contributing to the chief complaint of low back pain.  It did not go as well as I hoped it would, mostly because I am uncomfortable with calling people out about their weight but that is something I am going to have to get over in order to better serve my patients.  Sometimes “tough love” is essential.

We had quite a few patients with fibromyalgia present this week and one with HIV/AIDS.  We altered the care a bit for the fibromyalgia patients in that we used the low force activator to adjust them, so that we wouldn’t put too much input into their already overly sensitized nervous system and send them into a “flare up.”

We didn’t change anything for the patient with AIDS which I was happy about.  In my experience, having worked in a hospital, people with AIDS are often handled with kid gloves or severely isolated out of the provider’s fear of the disease.  My heart goes out to those that are treated as less than human due to their unfortunate circumstances so it was great to see that Dr. P made the patient feel like any of his other patients.

Another patient story: a while ago a patient was referred for to Dr. P for care, but when Dr. P saw the patient’s x-rays he thought the bones looked too demineralized for the patient’s age.  He sent the patient out for bone density testing and found that his density was dangerously low.  As a result, the patient’s primary care provider put him on a regimen of Fossamax and when we saw the patient he reported that his bone density score has improved from osteoporosis status to osteopenic status, which is great news!  The patient was so grateful for the catch! And he continues to see Dr. P for chiropractic care.

We had a fun encounter this week in which one of the nurse practitioners (a highly trained nurse…basically the “doctor” of nurses) that works down the hall, wandered into the office with some pain in his scapular/rhomboid area.  He started out explaining the pain he felt and then asked Dr. P if there was anything we could do for him.  Dr. P explained that his description sounded like a case of vertebral misalignment and offered to adjust the NP.  After adjusting him, the NP felt much better and then proceeded to ask a bunch of questions about chiropractic and its premise.  The NP was very receptive to all that we discussed.  It was very cool to be able to enlighten him on how we address the body and have that educational moment with another healthcare provider that was not “in the know” about chiropractic.

Other fun things that happened this week were that I was able to put in my first official notes into the charting system and I was strapped into a traction machine.  Putting my first notes into the charting system was kind of intimidating because it goes into the patient’s permanent record in the VA federal database.  I had Dr. Pavalock look at and okay the first few before signing them, just to make sure I wasn’t forgetting anything crucial but now that I’ve got a good template down, I am up and running with charting.  Pretty sweet!

One of the days Dr. P wasn’t able to come in but he asked that I go in and read up on proper documentation.  Once I was finished with that, I went down to the chiropractic therapy suit and pestered James for a bit.  They use the same electrotherapy machines as we’ve been trained on at school so I didn’t ask too much about them.  The traction machine, on the other hand, is something that I have no experience with so I had James give me a tutorial and strap me in.  I got to experience what lumbar and cervical traction feels like for the patients, which is great.  As they say, experience is the best teacher.

Outside of the clinic, it was a pretty boring week. On Friday though, my roommate invited me to a birthday dinner for one of her friends.  We went to a restaurant in downtown Jackson called “Julep.”  It had a nice, muted atmosphere with very good food.  I tried my first battered eggplant fries which were quite tasty.  I made the table giggle when I asked what grits were.  Apparently I need to go to a restaurant named Table 100 to get the best shrimp and grits ever…putting that on the to do list, along with a crawdad boil.

Stay tuned for more fun adventures from the south!

Alicia Ruiz, 10th Trimester Student
Davenport Campus

Frustration ensues

Well, I am beating myself up slightly.  I knew coming here that I would be working with a different subset of people than I was used to and that it would not be easy adjusting military men.  The first week I was following him, Dr. P even had a discussion with me about how all of his students have hit a point in which they have had difficulty adjusting many of the patients and consequently they felt their skills were sub-par.  He told me to expect it to happen and when it does to not doubt myself but realize it is a part of the growth process.

This week, I hit that point.  The first couple weeks, I was adjusting at least half of the patients (he would allow me to) with minimal problems but now I seem to be missing most everything!  In my defense though, I haven’t been able to focus as much as I would like due to some dental woes that are keeping me up most nights.  That excuse aside, I realize that life always presents such challenges and when I’m out in the world on my own I’m not going to have an experienced doctor to fall back on so I need to always bring my ‘A’ game regardless of personal issues.  Subsequently, next week I am determined to be more patient with myself and to not have Dr. P step in to adjust unless I absolutely have to.

On a good note, I performed my 3rd new patient physical this week and it went SO MUCH more smoothly than the other two times!  Dr. P let me run the show, other than stepping in once to have an educational moment with the patient and I was grateful that he did.  The patient was a male in his 40s, not long out of the military, not working, and presenting with low back pain.  Dr. P had a discussion with him about staying active (ok, yeah I could’ve done that) and about the importance of reintegrating into society constructively.  He stated that he’s seen so many veterans from the Vietnam era isolate themselves and do nothing but sit in front of the TV, eat, drink, and waste away and he told that veteran not to fall into that trap.  He told the veteran to get involved in something that keeps him connected to society and keeps him feeling productive even if he cannot work.  That counseling was really good for me to hear, as it hadn’t really crossed my mind that this 40 year old guy could have such an issue and I had been so focused on the mechanics of doing the evaluation that I would’ve missed the opportunity to educate the patient.

The interesting case for this week was a male in his mid fifties that came in with neck pain and numbness and tingling in his left fingertips.  Looking at his x-rays, he had a surgical fusion of his 3rd and 4th cervical vertebrae (which had been performed in February of this year), he had not had numbness and weakness in this hand prior to the surgery but it has been present ever since the surgery.  Looking at his pre-surgical MRI, the bones and spinal cord at those levels looked relatively fine while at C5-T1 had substantial disc bulges and his spinal cord in that area looked wavy…not a good thing.  Also, when we performed all of the orthopedic and neurologic tests the findings pointed to the C7-T1 area as being the culprit.  We decided not to adjust yet and sent him off for a new MRI to see how the tissues in his neck have changed since his surgery 8 months ago.  I felt sadness for the poor guy because I could tell he was scared and freaked out about not being able to feel his fingertips and also because I know that the disc impingement on the cord has been long standing enough that even with a surgical removal/repair of the discs in his lower neck, he will probably always have deficits in his hand.

Enough shop talk.  My days outside of the VA consist of frequent walks with my roommate’s dog Gizmo and working out at the YMCA that is within walking distance of where I’m staying.  The location is pretty sweet because its right on a lakeside park so when I finish working out I wander to the waterfront, out onto the dock, sit and dangle my feet over the water and Zen out for a bit watching the water and wild life and listen to the water hit the shore.  It is very peaceful.

I made pumpkin pie from scratch this week and brought some in for Dr. P and James, they both enjoyed it and it turned out fabulously. Otherwise I’ve just been studying for Part IV National Boards coming up AND I found out that I passed Part III that I took back in September, YAY!!!

That’s pretty much my status report for this week.  As always, thanks for reading and I’ll talk to ya again soon. 😀

Alicia Ruiz, 10th Trimester Student
Davenport Campus

Slow week = area exploration

This week was a little slower than last week as Dr. P’s son was sick and he took a few days off to stay home with him, so I was only in the clinic on Monday and Friday. With three days off in the middle of the week, I decided to drive around and explore the area.

I have found 2 beautiful lake side parks that are within walking distance from where I am staying, one of which has a YMCA on the grounds as well…SCORE! I have also found a couple of malls, a few restaurants that look like some good eats, and while jogging in the area I stumbled upon a martial arts school. Anyone who knows me and my mini “obsession” with martial arts would not be surprised that even though I was pouring sweat and heaving for breath, I cut across traffic and jogged my way over to the school and stopped in to check it out. It was a nice facility and the Korean woman running classes was super nice. I had contemplated joining for a few months in order to get my kick on but sadly it was a bit too spendy and I couldn’t justify the expense while I’m here in MS.

Last week was the last week of the Mississippi State Fair in Jackson and my roommate took me Sunday evening. It was probably the biggest fair I have seen so far. The food midway was HUGE and the rides were pretty standard except they had two of the more popular rides. Even with doubling up, the lines were RIDICULOUS! I tried “chicken on a stick” which was a kabob of chicken breast chunks, onions, and dill pickle slices, all battered and deep-fried. Even though I’m not a big fan of deep-fried foods, it was pretty tasty. I didn’t ride any rides but did enjoy some people watching!

Even though I was only in the clinic for two days this week, it was a big week for me. Dr. P allowed me to adjust a few patients and even let me do an entire established patient work-up, paperwork and all. Even though the adjusting table in his office is a bit too tall for me, I have been doing pretty well at adjusting on it. I have been getting a lot of pointers on my technique and it is refreshing to see that Dr. P really goes back to the basics of those techniques. He has had me adjust 2 of his patient’s necks in cervical chair (meaning that they are sitting up in a chair) and even though I feel weak in this technique due to lack of practice I have been doing ok with it. Although Dr. P did tell me Friday that my setups were “ugly,” he is determined to help me perfect my technique in cervical chair which I am VERY excited for.

The interesting case this week was an elderly gentleman that came into the office. Initially, I noticed a few growths on his face and neck. As I observed more, I could see more growths through his shirt and it made me start thinking. “Oh man, here comes national boards questions to haunt me again….what the heck was that disease in which the person is covered in a bunch of nodules?  Hmmmm. Processing, processing, racking the brain….eureka! Neurofibromatosis!  Could it be?” I wandered over to Dr. P’s computer and pulled the patient’s file up while the doc was working with the patient and after scrolling down the gentleman’s co-morbid list, there it was! Yay! I have just seen my first real life case of neurofibromatosis AND I remembered what it was! For those that don’t know this condition neurofibromatosis is a disorder in which nerve tissue grows tumors that are normally benign. For more information and to see what it looks like, check out the following link: http://en.wikipedia.org/wiki/Neurofibromatosis.

Well, that does it for this week’s post. As always, thanks for reading and I hope you have a great week! See ya next time!

Alicia Ruiz, 10th Trimester Student
Davenport Campus

The move and week one at the VA

It’s been a couple of weeks since my first post and quite a bit has happened.  I successfully conquered my finals and clinic requirements and spent my last few days in Davenport with friends and loved ones.  Sunday, Kyle and I loaded my car with the 6 bags full of my belongings and I took off.

It took me about 14 hours to get to Jackson.  The drive was pleasant and uneventful.  The scenery was beautiful with TONS of trees and I arrived around 11 p.m.  I spent Monday unpacking and getting settled into my new room, as well as getting to know my new roommate, Crystal, and her cute little dog, Gizmo.  Crystal is very kind, accommodating, quite talkative, and so far has been the epitome of “southern hospitality.”

Tuesday was my big 1st day at the VA.  My first shift started at 8 am.  Even though the VA is only about 30 mins from where I am staying, I left an hour early to account for traffic and to make sure I had time to recover from getting lost, as my Garmin tends to take me on some wild adventures.  Just as I suspected, the Garmin took me for a ride and I ended up having to call Dr. Pavalock to figure out how to get back.  Apparently, the Garmin took me to the “bad” part of town but I was able to find my way back and was about 10 minutes late to my first shift.  At least I had called Dr. Pavalock, so he knew I’d be late.  Great first impression.

So now on to the meat and potatoes…my first day.  We saw 6 patients the first day, three of which were new patients.  It was very interesting to watch how Dr. Pavalock interacted with and assessed all of the patients.  I was comforted by the fact that his new patient assessment and chiropractic assessment were very similar to what I have been doing with Dr. Crisp for the last 8 months of my clinical experience.  Although Dr. P is a Palmer graduate, it is cool to see that even after being out for 15 years (I think that is how long it’s been since he’s graduated) his assessment has not diverged much from the core of what he’s been taught.  It is reassuring to me that what I am learning will serve me well for years to come.  Dr. P has a great sense of humor.  I told him that I am from Montana and grew up on a farm/ranch so now I am branded (no pun intended) as a “cowgirl.” Although, Dr. P and has been teasing me about not being a “real” cowgirl because I’ve never used a bull whip and don’t know how to rope animals, lol.

Another interesting note about Dr. P is that he wears nitrile gloves while assessing his patients.  I asked him why and he said he wears them for multiple reasons.  He first wore them because he had burned his hand on his oven one day and didn’t want to rub his open sore all over his patients while working with them.  Pretty gracious of him, don’t ya think?  Hee, hee . Then he decided that the gloves were a good idea not only to protect his patients but also to protect himself, so the gloves have stayed.  When I get to start working with patients, I will have to wear gloves as well because the patients are used to it and expect it.  I am a little nervous about wearing gloves because I’m worried it will make my ability to palpate more difficult but then again when I transitioned from the student clinic to the public clinic I had the same fears about assessing patients without gowning them and its only a matter getting used to what you have to feel through.  By the time I’m done I will be able to feel a penny through a phone book, lol.

So onto some interesting cases….day 1 we saw a patient with neck pain and numbness in the fingers of his left hand.  The strange thing was that even though he stated his fingers felt numb, while assessing his sensation in that arm he had increased sensitivity to light touch and decreased sensitivity to sharp touch in the C7 dermatome.  For those not familiar, light touch usually is the first thing to go when someone has numbness.  His right side was normal and his x-rays showed some degeneration at C5/C6.  Because the neuro tests came up as so strange, Dr. P did not adjust him and sent the patient for an MRI.  The next day the radiologist called and reported that the patient had an infection in the disc between C5 and C6 that was eating the vertebrae above and below it….MAJOR contra-indication to adjusting!  Dr. P consulted with the patient’s primary care provider and he is now being managed appropriately.

Another patient presented with low back pain and his x-ray showed the biggest osteophyte (bone spur) off of the front of the sacrum I have ever seen!  It even took on the shape of the anterior of the disc and looked like a big claw off the front of the sacrum, almost connecting to the bottom of the L5 vertebral body.

Another patient with low back pain had some modic type 1 changes on his MRI in the L2/L3 area, meaning that he has some bone marrow edema going on due to degeneration.  Dr. P was curious about the findings on the MRI and so we went to chit-chat with the radiologist about it as well as to discuss the case of the patient with the disc infection.  The radiologist explained the modic types to us and then brought up a very interesting point.  The radiologist said that while the modic changes are something to be monitored, it is not terribly concerning and usually resolves itself but there is the potential that the edema/inflammation seen there could develop into an infection and become an osteomyelitis/discitis situation as we saw in the other patient.  This was interesting to me because as we learn it in school, the two seem very separated.  When you see modic changes, you think of it as simply evidence of degeneration happening in the spine which happens due to normal wear and tear of life BUT what if an organism does get into that inflamed site?  So my self-inflicted homework this weekend has been to find out if this has happened and been documented in literature.  If it has, how likely is it to happen, what could cause it to happen, and what is the appropriate management?

So far,  I have spent at least an hour or two every night looking up various things related to my day and I find it funny that I am doing more homework now than I did at school.  As Dr. Crisp would say “Welcome to Practice!”  It is awesome though and reassuring that the learning curve is going to be tremendous while I am here.

Well, this has been a LONG blog post so I am going to cut it off now.  Thanks again for reading and I’ll update you all again soon.  Until then, have a good one!

Alicia Ruiz, 10th Trimester Student
Davenport Campus