Reflection: Long-term Care Rotation

Having worked in transport EMS I had spent a bit of time bring patients in, and taking patients out of, skilled nursing facilities and rehabs.  In fact, I had been to this rotation site many times in the past which had me pretty excited to see it from a new perspective.  This rotation provided a great environment for really delving into a new patient’s documentation and history in order to establish a care plan, while also addressing the more acute events occurring with patients who have been admitted for quite some time.  While working closely with my preceptors, I was able to follow them through rounds in the morning, as well as sitting in for the morning meetings, and get a sense for how to best approach this patient population.  

One particular skill that I was able to work on during this time was evaluating a patient’s current medications and determining if any changes could or should be made, usually to reduce the number of different medications a patient is taking before they are discharged home.  This was especially important regarding diabetes management as most patients admitted to rehabilitation had been transitioned to various insulin injections as opposed to their usual PO medications taken at home.  On the other hand, some patients were actually on injection medications at home to begin with, and we would make sure to gather details of which particular devices or needles they were comfortable using and make sure these were ordered at their pharmacy.  

I was really pleased with the number of patients I was allowed to see on a daily basis, and there was certainly no shortage of monthly evaluations or new admission comprehensive assessments to take part in.  My favorite in particular were the visits for new complaints or abnormal daily labs and/or vital signs.  Again with diabetes management, there were often patients who needed to have their fingersticks closely monitored as insulin dosages were adjusted to best control their blood sugar levels.  These types of fundamental issues will serve me well going forward regardless of the setting in which I might practice, and the repetition of many similar cases was great for me as a student to help really store away the knowledge.  

The experiences that will stick with me the most are undoubtedly the patients that I got to know while on this particular rotation.  It was honestly somewhat difficult to say goodbye as many patients were there for the duration of my five weeks.  The importance of “soft skills” seemed especially crucial with these patients.  Being mostly elderly patients who had many chronic health issues and have spent a lot of time in and out of hospitals, you could really sense how much they appreciated having a student that was able to spend a little extra time just to talk with them.  This extends even to visiting family, who understood of course that I was only a student, who at times would even explicitly express that they were happy to “vent” their concerns to someone.  This made it even more satisfying when there were actual instances where I could in fact take their concerns to a provider and work out solutions.  These were the kind of interactions that helped make this a rotation especially enjoyable in the clinical year.  

Journal Article With Summary

Hohenberger C, Hinterleitner J, Schmidt NO, Doenitz C, Zeman F, Schebesch KM. Neurological outcome after resection of spinal schwannoma. Clin Neurol Neurosurg. 2020 Nov;198:106127. doi: 10.1016/j.clineuro.2020.106127. Epub 2020 Aug 4. PMID: 32768692.

The journal article I chose for this rotation was entitled “Neurological Outcome after Resection of Spinal Schwannoma”, published May of 2020 in the journal Clinical Neurology and Neurosurgery.  I chose this article because it related directly to a patient I had seen numerous times and got to know a little.  They had surgery years prior for a spinal schwannoma and had residual neurological issues that resulted in decreased mobility and repeat falls.  This article provided a great summary of spinal schwannoma while also investigating the factors that affect the more immediate postoperative neurological outcomes.  

According to this articles introduction to spinal schwannoma, the disease is the most frequently diagnosed benign spinal tumor.  It comprises approximately 25% of all intradural spinal tumors, with 0.3 to 0.4 cases per 100,000 people.  The majority of spinal schwannomas are benign and usually asymptomatic for long periods as they are slow growing.  Symptoms do not generally present until the schwannoma is large enough to cause compression on the spinal cord or nerve roots.  A complete resection of the affected nerve root is sometimes necessary to excise the tumor, with transient or even permanent deficits possibly developing.  

In this study, the mean duration of symptoms was 3.6 months, plus or minus 1.6 months, with a range of 0-6 months.  The most common presenting symptom was local back pain, followed by radiating pain, sensory deficits, and motor deficits.  Urinary retention occurred in 3.3% of cases, and loss of sphincter control in 1.1% of cases.  In the post operative period they found that 59.7% of pts had complete recovery from local pain, while 69.5% of patients had complete recovery from radiating pain, and 27.7% of patients developed a new neurological deficit, of which the vast majority were sensory deficits.  At 12 months, 100% of patients made full motor recovery, while 69.5% of sensory deficits were recovered.  They found that the most significant predictor for functional outcome following surgery was intraoperative monitoring, or “IOM.”  IOM is used to monitor neural pathways during neurosurgical procedures considered high risk using various procedures and modalities.  IOM is used to detect potential damage to the spinal cord, brain, peripheral and cranial nerves.  Uses for IOM include carotid endartectomies, aneurysm repair, brain tumors, and tumors of the spinal cord.  In this study, there were 44 patients with IOM, and 46 without.  They report that 37% of patients without IOM suffered new neurological deficits following surgery, while there were only 18.2% with IOM.  Needless to say, they made the recommendation that IOM accompany spinal schwannoma resections to ensure the best outcomes possible.  

Site Evaluation Summary

My site evaluations with Dr. Davidson were a great learning experience that included going over 3 complete history and physicals, 10 pharmacology cards, and 1 journal article discussion.  The first H&P we discussed involved a patient with a past medical history of heart failure, coronary artery disease, hypothyroidism, anemia, and oropharyngeal squamous cell carcinoma diagnosed in 2008.  They had underwent chemotherapy and a right neck dissection at the time and have followed up regularly, being ‘cancer free’ since then.  The patient had recently been hospitalized for an aspiration pneumonia, having had a history of aspiration due to dysphagia secondary to their esophageal cancer treatments.  On admission the patient was midway through a course of levofloxacin and stated they were feeling quite a bit better but with impaired mobility following hospitalization.  The discussion around this case mainly involved the physical exam and paying special attention to sites of potential metastasis that may have gone unnoticed previously, such as palpating irregularities in the border of the liver.  The second H&P involved a female patient in their 90s with a past medical history of hypertension, CAD with stent placement, and COPD who suffered a fall at home, fracturing their right hip.  While hospitalized they were found to be hyponatremic and diagnosed with SIADH.  Our discussion involved their differential for the cause of this patient’s SIADH, which ranged from pulmonary disease vs. pain vs. adrenal insufficiency of uncertain etiology.  The third H&P involved the patient who had a resection of a spinal schwannoma, after which we went over the journal article on the subject as well.