Wakey , wakey eggs and bakey
Frick Frack
Interesting
Innit Interesting?
Sweet Pea
Wild child
Peanut
-Dr. Justin Beverly (Pediatric Attending, Pimp Master)
So, Pediatrics, one of the most enjoyable and crazy rotations I've done so far.
I started off my Peds rotation on the floor and I'll say this much, the floor is intense. We worked like interns for lack of a better description. I was fortunate in the sense that there were four of us on the floor team. 1 student was always rotating on the PICU (Intesive Care Unit) while the rest of us remained downstairs.
So couple things to understand, the Children's Hospital is separate from the main hospital. You cross a bridge on the 4th floor of the main hospital to get to the third floor of the children's hospital, doesn't make sense to me either. Perhaps there's some kind of wormhole/vortex between the two buildings. Once you cross before 6am. well you don't go back till lecture at noon.. it's a completely different world. I'm thinking bridge to Terabithia except this Terabithia is full of RSV, contact precautions, tee-tee and poo poo. (But I digress, and btw just as an aside.. that movie "Bridge to Terabithia.. was really sad) Lastly, the bridge is one of the few areas in the children's hospital that has windows so really it is very possible you will have no idea what's going on outside during the course of the day until you cross the bridge on the way out the door for the day.
There's paintings on the wall and drawings submitted by past patients and bathrooms where everything is smaller. Since you're there at 6am , the nurses are winding down before shift change so there's a sort of lull in the predawn period. Then you make your way to the dungeon, the peds conference room. Here is where it all takes place. Here's where we divy up our patients, work on getting people home, changing orders, calling hospitals.. this is the think tank behind everything the pediatric team does on the floor. So begins the day
600-700a - Students wait for Interns (First Year Residents) to show up and sign out = the on call intern from the night before tells the intern coming on about anything crazy that happened or any new admissions, the students have to pay attention because we have to split up the patients as well
700a-930a - pre-rounds - visiting patients , checking labs, writing notes on the patients we have, this includes touching base with our intern before it's time for work rounds
930a-noon - work rounds- the whole team goes patient to patient and a student/intern presents the patient example: 12 y/o male presents with 5 day history of constipation and distension unrelieved by over the counter fiber supplements , he is currently on IV Fluids and a Go-Lytely drip. Labs are normal, etc etc. Constipation is a rather common problem. All joking aside, it's really obstructing medical care... HAHAHAHA (get it?) So work rounds is similar to what you see in Scrubs where the attending asks questions at the bedside, etc. One of our attendings, the one I quoted at the beginning is famous for his bedside questioning.
Noon - 130 - Lecture and Lunch
130-500p - Anything and everything that needs to get done on the floor from orders, discharges , new admissions, checking on patients, calling outside hospitals, calling the lab, etc
Then there's night call. Because of the holiday season, our night calls got stacked up. So instead of spreading six nights of call over 4 weeks, I had 3 nights of call two separate weeks = 90-110 hrs logged at the hospital ... KILLER. There's not a whole lot that's crazy about night call. Essentially the day team leaves and checks out to a night team. The night team just handles whatever takes place at night, writing for meds and handling new admissions. The only difference is that we have to call the attending at home to discuss patients before we admit them. As a student, we picked up whatever admissions we took part in. Since we usually write the admissions orders and take the histories, we know the patients quite well. So the next morning it'd be your responsibility to present the new patient. So let me digress and talk about beeepers:
I used to think having a beeper was awesome. It was some kind of reminder to the outside world that your were awesome and that somehow attractive ladies would realize that obviously you're some kind of important doctor who needs to rush off and call about pages and save lives.
I don't think that anymore. You see the beeper is your means of contact when you're not near your resident. So you think you're home free around 1100p/midnight and you settle in for uncomfortable night in our call rooms trying to get some semblance of somber when it goes off, the beeper ... the bastard of a beeper. It's 300a and you just sigh audibly.... and say something like SON OF A FRICK FRACK. So what is a beeper? It's a cock block of peace in your life. The funniest thing to observe is the collective loss of sphincter tone in a group of medical student when someone's beeper goes off. Everybody is sitting around our student lounge when it goes off. There's a little pallor in the face and we all hesitate, reach for our beeper and realize it's one unlucky soul's page and not our own. Realizing we didn't mess ourselves, we are all collectively relieved but silently mourn the poor colleague. So long beeper bitch, we shall live another day.
So a few things that I've seen on the floor that was interesting:
I took care of a little girl with Kawasaki's disease - basically a vascular disease in kiddos that can cause Heart Attacks in kids.
We has a cute bilingual kid who ended up with a wicked Strep Pyogenes skin infection.
We had a bunch of RSV-ers
I had a run of the mill abscess kiddo
I'm blanking on other things but yeah
So after my 3 weeks of floor madness, I had one week of PICU. PICU was awesome. Now here's a little dose of irony. The PICU, the Pediatric INTENSIVE Care Unit is less intense than the floor. My resident and attending were really laid back people. There's several reasons why the PICU is cool. One , you don't have to take as many patients. I started with one patient, a little dude who had RSV and was on a ventilator.
So time for another aside.
RSV - http://en.wikipedia.org/wiki/Respiratory_syncytial_virus
RSV is one on the most protean viruses known to mankind. Well, maybe not mankind so much but Robert-kind. You see with kids, most kids end up with a coughing spell that lasts for a bit and lingers, maybe a little tachypnea. Some kids need a little oxygen support and chill on the floor. Other kids, like my little man in the PICU end up being put on the ventilator , especially if they are premature babies. They just don't knock the virus out fast or strong enough.
It's weird entering a room with a little one hooked up to a ventilator and recording settings and checking tube feeds and medicines including an array of muscle relaxants (Versed and Fentanyl) . My job was basically to check his lungs, check hsi xrays, check his feeds and see how he was doing. It's strange watching the lungs slowly clear up and then hearing them clear up on exam. But that's PICU for you, you manage the basics.. airway, breathing, circulation....
So mid week I decide to pick up another little man. This little dude was a 4mo old male with Down's syndrome and had an AV canal which means , he really didn't have a nice separation of inflow and outflow in his heart
His main problem is that he'd have these spells where he'd desat (lose oxygen, turn blue) and brady (slow his heart) and it was thought that we was just shunting during these periods. He has a particular formula where he'd get fussy --> arch his back --> get worked up ---> mess his diaper --> desat/brady and then you'd just turn his O2 up a little and wait and he'd go back to normal. Well this little guy decided to do this to me and the nurse one morning. The nurse hadn't been seeing him and wasn't acquainted with these episodes but during my morning exam, he went through these steps and it played out something like this:
[Robert is examining his patient, putting his little nasal canula back on and trying to pat him back to sleep]
[Little dude starts arching back and turns gray/blue]
Nurse: He's desating , he's turning grey-blue
Nurse: where's the bag, bag him, bag him
Robert: [no words, proceeds to grab ambubag and starts inflating]
Nurse: it's not connected, where's the connector, oh my God
Robert: [is scared crapless... holy crap this kid's gonna die on me... what am I even doing?]
BREAK - so you need to realize that while all this is going on. There's a 16 y/o male with sickle cell who had respiratory issues, heart failure and kidney failure and all this stuff going on that early morning and they were trying to stabilize him to get him sent to Egleston so the PICU was busy. Also realize the rooms are transparent in PICU, nothing goes on without us really knowing
Robert: [thinking, where is everyone , holy crap holy crap.... ]
Respiratory: calm down, this kid does this
My Resident: walks in
- everything calms down as the little guy returns to normal, is breathing fast with retractions but otherwise going back to normal with some eye contact issues (maybe a little seizure activity?)
But that was PICU week, back to the basics... tweaking ventilator settings here and there... swapping out meds and fine tuning most patients. Rounds consisted of checking all new xrays, and visiting each patient with the nurse in the room, the resident, the student , the NP, and the respiratory therpaist all contributing. It's a very team oriented approach on PICU. Nobody is alone, everyone helps take care of the patient. It can get really crazy in a hurry but mostly it's just watch and wait. I enjoyed PICU alot and learned alot and also almost crapped my pants like my little guy who does crap his pants after almost dying....
That same little guy was smiling later that day as we checked on him. My resident commented "look at him smile while we talk about him almost dying" This is why I love peds...
One reason not to do peds is loss. We lost one of our patient en route to NY. He was an 8 y/o boy newly diagnosed with cancer in August (he was actually diagnosed when I was pediatric surgery and we were checking his chest tube to drain a suspicious effusion). Later, he returned for a little fever, upset stomach when I was pediatrics and he just had some cruddy looking lungs , earning him a ticket to the PICU. Well , he was starting to do better, on high flow oxygen and was ready to be transported to NY where cancer specialists up there were gonna better assist him. Well, he didn't make it for one reason or another, the family didn't want to do an autopsy. May he rest in peace.
So that catches us up to this past week, Newborn Nursery
So my only gripe with Newborn Nursery, I had to come in Sat/Sun morning but otherwise this was the greatest week on Peds for me. I showed up between 800a-815a and saw one or two patients and because of the holidays we had extra help so there wasn't any need to handle more patients.
Newborn Nursery is awesome, your patients range in age from hours to days, no more. Some of my babies, I'd see a few hours after being born. It's really unique in that babies are really durable straight from the get go. I mean they're ready to rock and roll straight out the bajingo. So the newborn exam... something the general public doesn't need to realize is something that I'm learning on the fly: The whole flipping the baby around and checking the head is really disconcerting if you realize that the person doing it is an amateur. I had one grandma who was very humored by me holding the baby in one hand and checking spinal reflexes.
So to top off my newborn week, I pulled a classic move during an interview, totally neglecting to check the gender of the new baby, I proceed to inform mom about spitting up patterns, stool patterns, cord care...etc then I casually proceed to talk about circumcisions ...etc.. and which point mom.. goes "she's a girl".... I'm like... oh.. so that's not relevant at which point mom, dad, my resident and I laugh at my faux pas. My resident totally covers for me by saying that it was unclear earlier the gender of the baby in the paperwork... thanks for that......
One of my favorite parts of the exam is eliciting the Moro reflex, basically you raise the lying baby up by the arms and drop them a little and their little arms should flail out as if they're startled... they do this too when you catch them off guard with a cold stethescope. It's their little way of saying "holy crap dude, take it easy"
Another one is called the galant reflex where you stroke parallel to the spine and their little hips swing to the side like a fish, "just keep swimming..."
So in short, this week was awesome. I worked from 815a-noon and then lecture noon-1 and then may or may not have a kiddo get born before 3/4p ... best schedule ever . One thing to marvel at is how healthy these little guys are. Mom may have STDs (which I've seen), mom may have done done drugs (have seen) and the odds may just be stacked against them but sure enough they start feeding, picking up weight and are sent on home......
This week more than ever convinced me that I will probably pursue a path in pediatrics. There's just something remarkably awesome about little ones getting better that makes you feel good. There's also this sense of high stakes. Kids will turn on you real fast. The healthiest looking kid can have an occult bacteremia /meningitis that just levels them within 24 hours. I think the patient population and the challenge , the stakes is what makes me attracted to pediatrics.
Plus, let's be honest... I can get away with saying things like "squishy", "poop", "whiny", "yucky" while giving report on pediatrics. The whole week, I wore a big ole button with a snowman. It's just so fun to take care of kids. Plus, let's be honest - "I help kids get better" bodes well with the LADIES....
Anywho, loyal readers
Merry Christmas, Happy Hannukah ... rest and relax....
Love,
Robert
