Saturday, December 17, 2005
Pediatrics is OVER!
Okay, so, like WOW. You may have heard/read me say before that I have a lot of people spontaneously telling me that I should go into pediatrics. Well, I can tell you this, if I do go into peds, I'm going into the outpatient setting! Inpatient was a pain in the ass! In all fairness, part of it had to do with the my team. I was on the neurology and pulmonology service and we were totally slammed with patients from day one. In fact, on my first day I had call (which is a 31 hour shift) and we admitted to our service 14 new patients with a total of 18 patients between two students, two interns and one senior resident. That is the same size as the three other the teams. Usually, there are about 4-5 patients per team and then occasionally 12. Over the next week, we actually went up to 21 patients. The team across the hall from us had 2. So, after about 10 days of this hell they redistributed our patients to the other teams. Of course my classmates in the other teams when from complaining how bored they were to how much work they have now that there team as 12 patients. 12 patients was a dream-come-true for us!
Aside: I have noticed and verified with my classmates that it's not just me whining. Which I certainly am doing. I have consistently gotten the short end of the stick (maybe that should be long end of the stick) on most of my rotations. Just bad luck I suppose.
Most of my days were like this: up at 4:30a -> at work by 6:20a -> leave work by 7:30p -> eat -> sleep. 6 days/week with three call night in there for good measure. When the shelf exam go closer I started studying until 10p. That's why I have not been able to post much.
On my first day off I tried to sleep in, which ultimately I did. But my bowels were ready to go at 5:30a. After all they're trained to be ready an hour early. (Like how I worked that in there?!) But, I managed to fall back to sleep for 4 more hours! :-) For may day off we had lunch at our little burrito place and then went sledding! (We just got back from 3h of sledding.) That's the most exercise I've had all month! And I needed it! I wonder why I'm using so many exclamation points?! I must be excited or something!
I did see many interesting cases on peds inpatient. Maybe more so than internal medicine. I had a kid with 12 fingers and 14 toes! Polydactyly is the official term. Post axial off of the 5th digits bilaterally on the upper extremities, for those of you that care. He was really cute! He was having some respiratory distress due to bronchiolitis (a lower respiratory infection) and needed some O2 for a could of days. They gave him some oral steroids too because he had some airway reactivity (it helped) but I really don't think he needed it--and I voiced my opinion as such. When we were talking about him someone made a remark about him having difficulty in math. I responded, "well he'll do great in base 12 or base 14!" One person in the room got it and he busted out. He said to me, "you realize that there is probably only one other person in the building that would get that joke." My other coworkers did just stare at me and blink..blink...blink. Reflecting on the joke, I suppose I could add in base 26 for completeness. In any case, the timing was there when it was actually told.
One of my other patients was a young lady (16) with an eating disorder that drank so much water she made herself hyponatremic (too little sodium in her blood). Her mom speculated that she drank over 18 liters of water that day. Usually she drinks about 12-16. It's a common thing that people with eating disorders do to make them feel full. She was one step away from having seizures and two steps away from coma. All we had to do with her was keep her from drinking water for a few hours and she peed her self back to good health. Unfortunately when she was unconscious she drenched the bed a couple of times. She has an impressively big bladder. As you might guess, she was in need of some serious help and was transferred to our psychiatry service once she was stable.
Around 3:30a on my first night of call I worked up a young man who had abdominal pain, passed out while he was getting ready to vomit (which he never did), and had altered mental status (was just not acting himself). Going through the physical I thought for SURE he had appendicitis! He had a mildly positive obtuator and psoas sign and his pain was around his belly button. Which is where the pain often is before it goes to the lower right side of your abdomen. The month before he contracted mono and was just allowed to play sports again. An abdominal CT showed mesenteric adenitis--inflammation/infection of the abdominal lymphnodes. Bummer, dude! I thought I had caught my first appe! His altered mental status cleared up over the next day after I was post call and so they sent him home. I think he should have received an head CT that night, but I was wrong. Actually, I think I was still right and it really should have been done in the ER because he could have knocked his head when he fainted. My attending (she's the one that sent him home) and I had a big long talk about it. Actually, a pretty good debate. She was a little surprised because I usually take the stance of fewer CT's because they deliver so much radiation. She said that had I seen him the next morning when he woke, I would have felt better but that she understood where I was coming from. She did not totally disagree but, the other point was that when the intern went to check for a hernia and perform a rectal exam, he perked right up. It was, after all, 4:30am and they had been up all night.
Another interesting patient was an 19 year old (get the impression that I did not see too many "children?") who had right pulmonary agenesis. Said more clearly: he ain't got no right lung. He was ventilator dependent because his throat did not stay open and he talked like Donald-duck: used an air pocket in his cheek to make sounds through his mouth. It took me about an hour before I could pick up about 50% of what he said. By the time he left I understood about 80%. He had become ill a few weeks ago and his ventilator setting had become much worse, so we were trying to figure out what was wrong. Anyway, he was a lot fun!
With all of that said, I think my favorite part of pediatrics was dealing with the teen population. With the exception of the girl trying to drowned herself.
The last really interesting patient was a 5 month old girl who was just not doing well. She wasn't feeding well and was not putting on any weight. It turned out that she had CF. (Talking to her mom she said that she (and the little girls siblings) always noticed that she tasted salty when she kissed her.) So this was the cutest little girl in the whole hospital and how diagnosed with CF. Her father, who was the primary care taker of all of the children, totally freaked out and was in denial in a bad way. As part of her work-up we found out that she had a UTI. Very uncommon for a child that young to get, so we started working that up with an abdominal ultrasound. You look to see if there is vesicoureteral reflux which, although common, can cause scarring. During the ultra sound, we found about a dozen masses in this little girl's liver and one large one on her right adrenal gland. That news did not help the family out much. After some more testing, there were no mets to the bones or the skin so the preliminary (and now final after removing the right adrenal gland) was neuroblastoma stage 4s. What is special about the 4s diagnosis is the cancer usually spontaneously regresses after removal of the primary tumor (85% of the time). We decided to wait to work up the rest of the UTI as an outpatient since the parents (especially the father) were at their limits of coping. My last day when I walked in to see her, she gave me this BIG'Old smile from across the room. She was smiling and cooing through the whole exam--she was usually a little fussier than that. I just melted! Who knew I was such a push-over? Wait, didn't I say in an earlier post that I was not a push-over? I guess I'm just a complex kinda' guy!
The rest of my patients were CF kids experiencing an exacerbation: they come in for a "tune-up" which takes a week or two. Also had a few bronchiolitis patients.
Now, we're just relaxing for the weekend and getting ready to leave town for a couple of weeks. We'll go to Florida to visit with ML's family and then up to Georgia to visit my family. Have about a week after we return and then surgery! Two months of no sleep. Yup! That's right! For all of the complaining I've been doing about not sleeping, I have yet to experience the worst of it. Surgery knocks the shit out of you! I'm going to try to study ahead of time (while I'm on break) so it won't be so freaking bad when I'm actually in it. May sound geeky, but hey, that's life.
I'd like to add one more comment. Today on CarTalk there was a young lady in college who called in about an old mustang. She made a comment that she had bet her parents that if she got 100% on her medical school entrance exam they would buy her a 1966 mustang. She claimed that she only missed one question on the exam. I would like to point out for the record, at least when I took the exam in 2000, you never new how many questions you got right. And, since the MCAT is scored on a sliding scale, there is no real way to tell, unlike the GRE where they do report the actual score. All you get is this strange number where the average score of all of the test takers is set to be 18 and what percentage you scored compared to the other test takes broken down into a few topics. And that's all I got to say on that subject. (Well, at least all I want to say here without a few beers in my belly.)
Okay, so, like WOW. You may have heard/read me say before that I have a lot of people spontaneously telling me that I should go into pediatrics. Well, I can tell you this, if I do go into peds, I'm going into the outpatient setting! Inpatient was a pain in the ass! In all fairness, part of it had to do with the my team. I was on the neurology and pulmonology service and we were totally slammed with patients from day one. In fact, on my first day I had call (which is a 31 hour shift) and we admitted to our service 14 new patients with a total of 18 patients between two students, two interns and one senior resident. That is the same size as the three other the teams. Usually, there are about 4-5 patients per team and then occasionally 12. Over the next week, we actually went up to 21 patients. The team across the hall from us had 2. So, after about 10 days of this hell they redistributed our patients to the other teams. Of course my classmates in the other teams when from complaining how bored they were to how much work they have now that there team as 12 patients. 12 patients was a dream-come-true for us!
Aside: I have noticed and verified with my classmates that it's not just me whining. Which I certainly am doing. I have consistently gotten the short end of the stick (maybe that should be long end of the stick) on most of my rotations. Just bad luck I suppose.
Most of my days were like this: up at 4:30a -> at work by 6:20a -> leave work by 7:30p -> eat -> sleep. 6 days/week with three call night in there for good measure. When the shelf exam go closer I started studying until 10p. That's why I have not been able to post much.
On my first day off I tried to sleep in, which ultimately I did. But my bowels were ready to go at 5:30a. After all they're trained to be ready an hour early. (Like how I worked that in there?!) But, I managed to fall back to sleep for 4 more hours! :-) For may day off we had lunch at our little burrito place and then went sledding! (We just got back from 3h of sledding.) That's the most exercise I've had all month! And I needed it! I wonder why I'm using so many exclamation points?! I must be excited or something!
I did see many interesting cases on peds inpatient. Maybe more so than internal medicine. I had a kid with 12 fingers and 14 toes! Polydactyly is the official term. Post axial off of the 5th digits bilaterally on the upper extremities, for those of you that care. He was really cute! He was having some respiratory distress due to bronchiolitis (a lower respiratory infection) and needed some O2 for a could of days. They gave him some oral steroids too because he had some airway reactivity (it helped) but I really don't think he needed it--and I voiced my opinion as such. When we were talking about him someone made a remark about him having difficulty in math. I responded, "well he'll do great in base 12 or base 14!" One person in the room got it and he busted out. He said to me, "you realize that there is probably only one other person in the building that would get that joke." My other coworkers did just stare at me and blink..blink...blink. Reflecting on the joke, I suppose I could add in base 26 for completeness. In any case, the timing was there when it was actually told.
One of my other patients was a young lady (16) with an eating disorder that drank so much water she made herself hyponatremic (too little sodium in her blood). Her mom speculated that she drank over 18 liters of water that day. Usually she drinks about 12-16. It's a common thing that people with eating disorders do to make them feel full. She was one step away from having seizures and two steps away from coma. All we had to do with her was keep her from drinking water for a few hours and she peed her self back to good health. Unfortunately when she was unconscious she drenched the bed a couple of times. She has an impressively big bladder. As you might guess, she was in need of some serious help and was transferred to our psychiatry service once she was stable.
Around 3:30a on my first night of call I worked up a young man who had abdominal pain, passed out while he was getting ready to vomit (which he never did), and had altered mental status (was just not acting himself). Going through the physical I thought for SURE he had appendicitis! He had a mildly positive obtuator and psoas sign and his pain was around his belly button. Which is where the pain often is before it goes to the lower right side of your abdomen. The month before he contracted mono and was just allowed to play sports again. An abdominal CT showed mesenteric adenitis--inflammation/infection of the abdominal lymphnodes. Bummer, dude! I thought I had caught my first appe! His altered mental status cleared up over the next day after I was post call and so they sent him home. I think he should have received an head CT that night, but I was wrong. Actually, I think I was still right and it really should have been done in the ER because he could have knocked his head when he fainted. My attending (she's the one that sent him home) and I had a big long talk about it. Actually, a pretty good debate. She was a little surprised because I usually take the stance of fewer CT's because they deliver so much radiation. She said that had I seen him the next morning when he woke, I would have felt better but that she understood where I was coming from. She did not totally disagree but, the other point was that when the intern went to check for a hernia and perform a rectal exam, he perked right up. It was, after all, 4:30am and they had been up all night.
Another interesting patient was an 19 year old (get the impression that I did not see too many "children?") who had right pulmonary agenesis. Said more clearly: he ain't got no right lung. He was ventilator dependent because his throat did not stay open and he talked like Donald-duck: used an air pocket in his cheek to make sounds through his mouth. It took me about an hour before I could pick up about 50% of what he said. By the time he left I understood about 80%. He had become ill a few weeks ago and his ventilator setting had become much worse, so we were trying to figure out what was wrong. Anyway, he was a lot fun!
With all of that said, I think my favorite part of pediatrics was dealing with the teen population. With the exception of the girl trying to drowned herself.
The last really interesting patient was a 5 month old girl who was just not doing well. She wasn't feeding well and was not putting on any weight. It turned out that she had CF. (Talking to her mom she said that she (and the little girls siblings) always noticed that she tasted salty when she kissed her.) So this was the cutest little girl in the whole hospital and how diagnosed with CF. Her father, who was the primary care taker of all of the children, totally freaked out and was in denial in a bad way. As part of her work-up we found out that she had a UTI. Very uncommon for a child that young to get, so we started working that up with an abdominal ultrasound. You look to see if there is vesicoureteral reflux which, although common, can cause scarring. During the ultra sound, we found about a dozen masses in this little girl's liver and one large one on her right adrenal gland. That news did not help the family out much. After some more testing, there were no mets to the bones or the skin so the preliminary (and now final after removing the right adrenal gland) was neuroblastoma stage 4s. What is special about the 4s diagnosis is the cancer usually spontaneously regresses after removal of the primary tumor (85% of the time). We decided to wait to work up the rest of the UTI as an outpatient since the parents (especially the father) were at their limits of coping. My last day when I walked in to see her, she gave me this BIG'Old smile from across the room. She was smiling and cooing through the whole exam--she was usually a little fussier than that. I just melted! Who knew I was such a push-over? Wait, didn't I say in an earlier post that I was not a push-over? I guess I'm just a complex kinda' guy!
The rest of my patients were CF kids experiencing an exacerbation: they come in for a "tune-up" which takes a week or two. Also had a few bronchiolitis patients.
Now, we're just relaxing for the weekend and getting ready to leave town for a couple of weeks. We'll go to Florida to visit with ML's family and then up to Georgia to visit my family. Have about a week after we return and then surgery! Two months of no sleep. Yup! That's right! For all of the complaining I've been doing about not sleeping, I have yet to experience the worst of it. Surgery knocks the shit out of you! I'm going to try to study ahead of time (while I'm on break) so it won't be so freaking bad when I'm actually in it. May sound geeky, but hey, that's life.
I'd like to add one more comment. Today on CarTalk there was a young lady in college who called in about an old mustang. She made a comment that she had bet her parents that if she got 100% on her medical school entrance exam they would buy her a 1966 mustang. She claimed that she only missed one question on the exam. I would like to point out for the record, at least when I took the exam in 2000, you never new how many questions you got right. And, since the MCAT is scored on a sliding scale, there is no real way to tell, unlike the GRE where they do report the actual score. All you get is this strange number where the average score of all of the test takers is set to be 18 and what percentage you scored compared to the other test takes broken down into a few topics. And that's all I got to say on that subject. (Well, at least all I want to say here without a few beers in my belly.)
Thursday, December 08, 2005
So it's fun to catch a baby even if it is slowly coming out of a vagina!
I'm been bad about posting, but it turns out that inpatient peds is really busy! At least our service. I'll post some stories about it AFTER the exam. In the mean time, here's a little story to tie you over: I was on call last night and I saw one of my neighbors in the hospital. He's in dental school and they work in the hospital from time to time but I knew his wife was pregnant and actually WELL past due. He said that she had finally gone into labor! (The day they were going to induce her. She was at 41+6 weeks! That's 41 weeks and 6 days in doctor-speak.) She's a slender gal and I've been telling her that she's been ready to deliver since about 20 weeks. As you can imagine, her belly was GINORMOUS! I asked her husband if it would be okay to stop in and say hello in a bit; it was; so I did!
We talked for a bit about how things worked and I asked her if she knew who her student was? She didn't have one. She said, "if you want to be my student, that would be great!" I asked her if she was sure since we're neighbors and all. She said, "I'd rather have someone I know helping than someone I didn't know." That was about 10pm. It took me about 30 - 45 min to ask all of the right people because, after all, I'm not on OB anymore. Fortunately the OB people on call all knew me and I was done with my pediatric responsibilities for the evening. I arranged to be paged when things really started moving along thinking that it would be around 2am with a 4am delivery. (Guess who was wrong about that!)
When my alarm went off at 6:10a, I brushed my teeth, ran a wet comb through my hair (which did not help at all!), and got up there by 6:20a to see how she was doing, figuring that she had delivered already. They were in there pushing and had been for about an hour. I had to go see all of my patients and I figured I'd miss it for sure. Did all of my morning stuff and had rounds (which seemed to take forever!) and finished all of my work by 11:30a, when I was set free. Got back down to the labor and delivery floor and they were still pushing! Actually, I figured she would have had a c-section by this point. I had to ask people again including the student that had arrived for her first day. She, the student, was okay with me being around because it was her first delivery and she was just going to watch anyway. Around 12:45p the decision was made to deliver with a vacuum assist. The baby was really close, but she had been pushing for a long time and was not making so much progress (the baby kept sliding forward and back again). The 9+ pound baby boy was born a little after 1p. Since it was a vacuum, I didn't get to actually deliver the baby (two doctors did it), but I delivered the placenta and then helped with all of the stitching. There was a fair bit of stitching to be done.
I was really nice to get one more delivery under my belt. Don't know if I'll do a sub-internship in OB next year just to do some more. I like delivering babies but the personalities you have to deal with (not to mention the hours) may just be too much for a career.
I'm been bad about posting, but it turns out that inpatient peds is really busy! At least our service. I'll post some stories about it AFTER the exam. In the mean time, here's a little story to tie you over: I was on call last night and I saw one of my neighbors in the hospital. He's in dental school and they work in the hospital from time to time but I knew his wife was pregnant and actually WELL past due. He said that she had finally gone into labor! (The day they were going to induce her. She was at 41+6 weeks! That's 41 weeks and 6 days in doctor-speak.) She's a slender gal and I've been telling her that she's been ready to deliver since about 20 weeks. As you can imagine, her belly was GINORMOUS! I asked her husband if it would be okay to stop in and say hello in a bit; it was; so I did!
We talked for a bit about how things worked and I asked her if she knew who her student was? She didn't have one. She said, "if you want to be my student, that would be great!" I asked her if she was sure since we're neighbors and all. She said, "I'd rather have someone I know helping than someone I didn't know." That was about 10pm. It took me about 30 - 45 min to ask all of the right people because, after all, I'm not on OB anymore. Fortunately the OB people on call all knew me and I was done with my pediatric responsibilities for the evening. I arranged to be paged when things really started moving along thinking that it would be around 2am with a 4am delivery. (Guess who was wrong about that!)
When my alarm went off at 6:10a, I brushed my teeth, ran a wet comb through my hair (which did not help at all!), and got up there by 6:20a to see how she was doing, figuring that she had delivered already. They were in there pushing and had been for about an hour. I had to go see all of my patients and I figured I'd miss it for sure. Did all of my morning stuff and had rounds (which seemed to take forever!) and finished all of my work by 11:30a, when I was set free. Got back down to the labor and delivery floor and they were still pushing! Actually, I figured she would have had a c-section by this point. I had to ask people again including the student that had arrived for her first day. She, the student, was okay with me being around because it was her first delivery and she was just going to watch anyway. Around 12:45p the decision was made to deliver with a vacuum assist. The baby was really close, but she had been pushing for a long time and was not making so much progress (the baby kept sliding forward and back again). The 9+ pound baby boy was born a little after 1p. Since it was a vacuum, I didn't get to actually deliver the baby (two doctors did it), but I delivered the placenta and then helped with all of the stitching. There was a fair bit of stitching to be done.
I was really nice to get one more delivery under my belt. Don't know if I'll do a sub-internship in OB next year just to do some more. I like delivering babies but the personalities you have to deal with (not to mention the hours) may just be too much for a career.
