Reflection

My Long Term Care Rotation at Margaret Tietz Nursing and Rehabilitation Center was useful. It was interesting to rotate in this setting, as I have some experience with Assisted Living facilities and Nursing Homes as a result of personal experience with my grandmother who suffered from Alzheimer’s Dementia. This clinical experience, while educational and at times very heart-warming, helped me recognize that Long Term Care, employment in a Nursing Home or Assisted Living, is not something I am interested in. I can say, however, that I thoroughly enjoyed my interactions with the patients, and personally think there is something very gratifying about speaking with the elderly and hearing about their stories.

Memorable experiences and patients I’ve had included caring for patients with very severe multiple sclerosis. Prior to this rotation, I was truly unaware about just how debilitating this disease could be. I recall exiting the room of a patient whom was contracted in bed with my preceptor when I asked her what the patient’s primary diagnosis was. I was shocked to learn that he was suffering from multiple sclerosis.  Other memorable experiences I’ve had included having the opportunity to join the wound care doctor on “wound rounds” every Wednesday morning. Seeing the patients decubitus ulcers improve over the course of several weeks through a variety of treatment options including calcium alginate, enzymatic debridement, etc. was very satisfying. Other memorable experiences I’ve had include working with one particular patient that had been admitted following multiple hospitalizations for pneumonia. This gentleman looked forward to seeing me every day, and it was an honor getting to care for him. He disclosed to me that he had been experiencing some anxiety lately, which he had never experienced in his lifetime (he was over 95 years old!) and I helped to encourage him to speak to the doctor and eventually to the psychiatrist and the psychologist about the way he had been feeling. This was a very moving interaction that I had with this patient, and his thanking me for my encouragement is something that I will not soon forget.

One component of the patient history that I learned was of particular importance in the Long Term Care setting is the Social History. Particularly, it is important for the clinician to explore the functional status of the patient prior to their admission, their living situation, and to even inquire about their previous occupation and other factors that could have contributed to their medical history. During my rotation, there were multiple instances where discharge was delayed due to difficulties arranging where the patient would be discharged to.

Another component of Long Term Care that I found to be a good learning experience was the interdisciplinary care between clinician, nursing, PT/OT, and social work. It was fascinating to see how dynamic the care of these patients is. Each facet of the care team must interact with one another to ensure that the patient is being cared for appropriately and that all steps of the admission to discharge process occur naturally. Furthermore, it was great to learn about how the process of consulting services occurs in the Long Term Care setting. Patients at Margaret Tietz Nursing, upon admission, would receive consults for podiatry, ophthalmology, and other services necessary services (like wound care doctor, psychiatry/psychology, etc.).

During this rotation, I learned how to measure patients decubitus ulcers, including if they were undermining and where the “deepest” location was. Moreover, I learned to monitor patients’ blood sugars and blood pressures to optimize their medications. Often times, the nurses would report to the doctor and I that a patients blood sugar or blood pressure has either been elevated or low over the past several days, and after checking the patients vitals and medication regimen, we would make certain adjustments and continue to monitor. During this rotation, I learned how to remove a PICC line. Though not challenging, it was a skill that I was initially apprehensive to perform, as I worried about infection and other complications.

The clinicians with whom I worked, Dr. Dugar and Dr. Shirvani, would explain their reasoning for medication adjustments and specialist consults for the patients. One of the things I enjoyed was being able to ascertain the HPI from the patient when they were a new admit and then present it to my preceptor. This was a good skill to work on, as patients of this age group tend to have many comorbidities, surgeries, etc. and other complicated social history aspects that are important to present in a concise fashion.

Some challenges that I had to overcome during my rotation were understanding the way in which Rehabilitation Centers and Nursing Facilities operate. For example, when beginning, I thought the patient load for most of the staff was too large. I later learned that this is pretty much the norm for most of these facilities, and in fact, that it is manageable by the clinicians caring for the patients. Furthermore, I learned that these facilities do not necessarily need to have a clinician staffed on site every day. It was interesting to learn about the function of a “Nursing Supervisor,” and in my experience, often times clinical situations would first be directed to the nursing supervisor who might then escalate by contacting the on-call physician if deemed necessary. Another challenge I had to overcome was that many elderly patients had either physical or mental ailments that impaired our communication. For example, many suffered from visual/auditory impairments in addition to cognitive impairment like dementia, sometimes making basic questions like whether or not the patient was in pain difficult to obtain answers to.

This rotation was a good review of a multitude of pathologies. These included orthopedic pathologies (namely hip fractures), psychiatric pathologies (namely depression/anxiety), cardiopulmonary pathologies (namely COPD, valvular disease, CAD), peripheral vascular disease, and others.

One thing I would want my preceptor and colleagues to notice about my work was the fact that I would spend adequate amounts of time with my patients. Multiple patients told me that they sometimes felt that their clinicians would have “one foot in and another out of the door.” I always made sure that my patients felt like I was available to them for as long as they needed me (within reason).

For the following, and final, rotation in Family Medicine, I wish to continue to expand upon my building rapport particularly with elderly patients. I wish to gain more comfort in discussing end of life issues such as early discussion of advanced directives and goals of care.

Overall, my experience at Margaret Tietz Nursing and Rehabilitation Center was educational.