As part of the McMaster Physician Assistant Education Program curriculum, each student shadows a professional in the field relevant to the unit being studied that month. These are called IER placements and students are assigned a half-day shift at a hospital/clinic in Hamilton. IER stands for Interviewing, Examining and Reasoning.
For this IER Placement:
- Medical Foundation Unit: Hematology
- Professional Shadowed: Hematologist
- Date of Placement: Wed. Dec 3, 2014
- Where: St. Joseph’s Healthcare Hamilton – Hematology Clinic
Read more about what I learned in my placement!
Small Education of the Day
Anemia is defined as low red blood cells or low hemoglobin. Most common type of anemia: iron deficiency anemia.
- What are Red Blood Cells (RBC)? RBCs are essentially boxes that carry hemoglobins (Hb), the structure that carries oxygen (1 red blood cell contains 250 million hemoglobins!).
- Where are RBCs made? In the bone marrow of the bones.
- What signals the body to make more RBCs? The hormone that signals the bone marrow to make more red blood cells is erythropoietin (EPO), which is secreted by the kidney.
- The kidneys release more EPO when not enough oxygen or blood gets to the kidneys. Eg. If there is low oxygen in the blood, due to anemia or COPD, there will be increased EPO secretion to instruct the bone marrow to make more RBCs.
- What do you need to make hemoglobins? Globin chains (alpha and beta protein chains) + Iron.
- Iron is what binds oxygen in hemoglobin!
If there are not enough iron in the body, the bone marrow cannot make hemoglobin or will make less hemoglobin. Without hemoglobin, smaller amount of red blood cells will be made with fewer hemoglobins inside them. As we recall, this is anemia = low red blood cells or low hemoglobin.
Four general causes for iron deficiency:
- Poor iron intake in diet
- “We are what we eat. We eat meat because we are meat. You are not a plant.”
- Some foods rich in iron are beef, oysters, leafy green vegetables.
- Increase iron demand (iron used up quickly in body)
- Occurs in teenagers who are growing
- Occurs in women who are pregnant
- Decrease absorption of iron
- As we age, our body is less efficient in absorbing nutrients.
- Either externally from trauma or internally from ulcers
- Females bleeding heavily during their period.
- Always consider iron deficiency in girls who just started having their periods and are feeling tired all the time.
I saw three patients with the physician, who were referred to him to find the underlying cause of their symptoms (mostly fatigue). A Hematologist deals with patients with other blood disorders, not just anemia. The most common symptom of anemia is fatigue.
The first patient we saw was a 42 year old female with chronic fatigue (over 10 years). Her chief complaint was feeling tired all the time, even after taking naps. She has to pull over on the highway several times because she was too tired to be able to concentrate on the road. This has greatly affected her life. She is not on a restricted diet and have tried oral iron supplements. She says that she has very heavy bleedings. The physician arranged for her to get IV iron on her next visit. Normally, iron is absorbed in duodenum of the small intestine but if iron absorption is the problem, patients can opt for IV iron. IV iron goes directly into the blood stream and therefore bypasses the absorption mechanism. The physician also suggested endometrial ablation to lessen the menstrual bleeding, assuming she is not planning to have any more children.
Our second patient was an 83 year old lady who has Chronic Obstructive Pulmonary Disease (on oxygen supplementation), Congestive Heart Failure and Atrial Fibrillation. Her blood test shows that her hemoglobin is low. We would expect patients with COPD to have higher hemoglobin because low oxygen levels in blood would signal the kidney to make more EPO, which in turns signal the bone marrow to make more red blood cells. However, if the patient was lacking iron, it does not matter how much EPO is secreted. The body just does not have the supply to make more RBCs. This is why the patient’s hemoglobin is still low.
In the PA program, we learn the proper and long way to do physical exams. In a real clinical setting, the physical exam is really focused and condensed. We are taught everything in the tool box but we are not expected to use it all on the job. It is so that when the time comes that we need to use it, at least we know how. It was good to see how the physician did his examination compared to what we learned in IER.
- With patient sitting up
- Auscultate back (listening to breath sounds)
- Percuss back (tapping the patient’s back to listen for dull spaces)
- Listening to heart sounds
- With patient laying down
- Pressing abdomen for tenderness
- Percuss abdomen (tapping abdomen to listen for dull spaces)
- Feeling for spleen and liver (looking for heptaosplenomegaly – enlargement of liver/spleen)
Take Away Points from the Placement
- As I was reading consult notes and associated labs with the physician, he was frustrated that the referring doctor did not do a ferritin blood test with these patients whom were referred for anemia.
- If there are any suspicion for iron deficiency or internal bleeding, do a ferritin blood test. Ferritin is a protein in the body that stores iron. If ferritin is low on a blood test, it may suggests that the person have iron deficiency.
- Bottom line: do a ferritin test to rule out likelihood of iron deficiency
- Women of child bearing age/going through puberty complaining about fatigue with low red blood cells/hemoglobin and iron, check if their menstrual periods are the cause of their iron deficiency.
- In older patients, iron deficiency may be from gastrointestinal bleeding (ulcers, hemorrhoids, cancer, etc). If suitable, they should do a colonoscopy to rule out GI bleeds.
My goals going into this placement was to see how a history is taken and what the plan is for the patient. I was able to see how the physician take a history and how he did his physical exam. Shadowing him allowed me to see what is important to look for in labs and things to rule out when taking a patient history. He was a wonderful preceptor (he even gave me a pen with his name on it as a souvenir!).
I really like going to placements because I find I learn best when I see things I learned in tutorial being applied in a real clinical setting. Sometimes in tutorial, we read about all the different symptoms patients present with and the different kind of treatments available but what I really want to know is which symptoms are most common and what is the first line of management.
Thank you for reading! Let me know in the comments below if anything I wrote down confused you or if there is anything I should add to my next IER placement experience post!