parent phone calls: episode II

04:44 5/27
mommy: yeah, i'm calling about my son. he's 8 months old. he's had this cold for a long time. 
girlMD: how long is a long time?
mommy: a couple weeks. he got some medicine for an ear infection last week, but i know his ear is still bothering him 'cause he's still digging at them. and now he's got this cough. 
girlMD: can you describe the cough at all?
mommy: well, it's dry but tight.
girlMD: any fevers?
mommy: no, not really.
girlMD: do you feel like he's having trouble breathing?
mommy: no. right now he's pretty calm. 
girlMD: alright. he's not flaring his nostrils or retracting or breathing fast?
mommy: no. he's drinking his bottle. 
(awkward pause as girlMD tries to figure out how to politely say, why the heck are you calling me at 5 in the morning if your kid is fine and has been sick for several weeks?)
mommy: well, i guess i'm just worried that you might think he needs to be seen now, instead of waiting until the clinic opens.
girlMD: well, if you don't think he's having trouble breathing, then i think it's ok to wait. our phones open at 8am and our appointments start at 9am. do you feel comfortable waiting until then?
mommy: yeah, i think so. we'll get some rest and call in the morning. thanks a lot.
girlMD: oh, you're welcome. 

lost art forms

the laying on of hands is truly a lost art form. tonight, i was asked by one of the floor nurses to come evaluate a baby who was quite agitated and setting off her alarms. this baby has quite a complex past medical history and has plenty of scary reasons why she could be setting off alarms. so, with respectful trepidation, i walked in to her room (after washing my hands, of course...hey, we've got a pertussis outbreak here).
she was lying in the crib, exposed, mottled, crying. her sat was 78, she was breathing 60-70 times per minute. i listened to her chest, a cacophony of sound that is a testament to her cardiothoracic surgeon in Boston. no crackles, though. no heart failure. no pneumonia to explain why she is needing more oxygen. she's still crying. i look around for her mother, who is usually, tirelessly, present. however, she is not. she is hopefully home getting some much-needed rest.
i decide to stand-in, imperfect as i may be.
i rub her back, make soothing sounds. shhh. you're ok. shhh. i covered her cold little feet with a blanket.
i look at the monitors, still blinking red alarms, but numbers that are moving in the right direction. respiratory rate down, oxygen saturation up. crying stops. she sleeps again.
the laying on of hands. it may just be coincidence, but i'm going to delude myself and believe that it worked.

parent phone calls: episode I

"Hi. I'm calling about my son. He's been crying for over 2 hours and I can't get him to stop."
(I listen intently to the background, waiting for the wailing she described.)
"Uh, what's he doing right now?"
"Sleeping."
This was at 1am. 

coffee break

i think coffee breaks are essential to sanity. we run ourselves ragged virtually every day. sometimes, we just need to stop, put our feet up and have a hot cup of coffee.
to what do i owe this luxury? well, both my attendings started their afternoon evals before i got back from noon conference.
i've already had one cup this morning, but there's no such thing as too much coffee.

nostalgia

i was browsing the itunes music store this evening and stumbled on their U2 collection. i was somehow magically transported back to summers with my best friend, sunbathing on her lawn and listening to war or october. this was before joshua tree, although we loved that, too, in it's time.
in our girlhood fantasies, anne was going to marry the edge and i was going to marry bono. no offense to larry mullen or adam clayton.
of course, we also pretended we were the go-go's, but that's a story for a different day.

conduct unbecoming

i met a disturbing child today.
6 years old, emotionally detached, without empathy. hurts animals, punches and kicks his brothers. yet, seeing him in the office today, you'd never guess that he could be so disturbed. he was pleasant, smiling, behaved himself tolerably well. but there was also a coldness to the quality of his interactions, even with his dad and stepmother.
i asked his father if he ever cried, like when he fell down and scraped his knee or something. "no, never." his father replied.
this is a child with conduct disorder. at the age of 6, this is indicative of something terrible happening to him at a very young age.
the goal of treatment for this child is to keep him out of jail. that is what would be success for him. if he learns to empathize with other people, that would be a bonus.
i left work today with this heaviness in my heart. what happened to this boy to make him so insecure in his world?

Discovering widgets

I love my Mac Powerbook. It's cute, portable, and has all these useful widgets. 

(Haven't you ever wondered what a widget was?)

I've just been browsing through all the new widgets (there are a ton) and found a blogger widget. All I have to do is type (as I am doing right now) in this little dialog box, hit publish post, and voila! Post accomplished. No opening Safari and typing in the blogger address, logging in or any of that nuisance.

Let's give her a whirl, shall we?

free to be

One of my favorite records has been re-released this week. Free to be you and me. One of the best children's albums of all time. Think my favorite was Atalanta, the story about the girl who won the race. Somehow, that one always stuck with me. That or the one about the girl who was eaten by tigers because, the lesson implies, she wouldn't share her mango. I know, it's hard to share mangos.
I highly recommend this album...I guess now it's a CD...for anyone with kids.
Think I'll get a copy for the ward. Seems like there are more than a few kids who might benefit from some timeless life lessons about freedom of choice, gender equality and talking about their emotions.

compassion

Three of the lacrosse players have been indicted in the Duke assault case. They claim that, while they may have been taunting her and generally disrespecting her due to her race and gender, they did not sexually assault her. The spokesperson for Duke University urged people not to jump to any conclusions, to exercise compassion and reserve judgement, as an indictment does not a conviction make. 

My question is, who was he urging to exercise compassion and for whom?

I can only hope he was referring to the three lacrosse players and their families, who are heaping insult upon injury as they scramble to clear their names whilst casting not-so-subtle aspersions on the character of this woman. let's all have some compassion for her.

"i didn't know they had hospice for kids"

Yes, hospice exists for kids.

The grandmother of one of my patients said that to me last week.

In the last week, I have learned the ins and outs of this all-important transitions. Two of my patients on the ward went home yesterday. By ambulance. One with a chest tube that persisted in pouring out fluid speckled with malignant lymphoma, the other with a body that was devastated at birth, yet still managed to allow one of the most beautiful spirits to inhabit the earth for a short time.

It's a sad time, but also a celebratory time. I didn't fully understand that until this week. This is the critical time for these families, now that they've made this most difficult decision, to celebrate the life of their child, their love for each other. Once that focus shifts, it's as if all the love just pours out.

Some families never get there. Perhaps there is something yet inside them that cannot let go. One of the families was in a most bizarre quagmire of arranging home hospice and comfort care, including the pre-hospital DNR/DNI order, but are still hoping that the alternative medicine treatments will save her. Her mother said to me as they were leaving yesterday that she hoped to bring her back in in a few months, a completely healthy girl. I smiled on the outside and murmured, "I hope so, too." On the inside, what I am hoping for is that they find the strength to let her go before it's too late for them to say goodbye, before it's too late to help her prepare for her death. She's 12. She's scared. She needs them now more than ever to guide her. I hope with all my heart that they can let her go so that her last days might be peaceful.

They are both wonderful children whose lives are far too short. But we love and care for them while they are here. That's the best we can offer, right?

a question of experience

Let me just say that this post is in no way intended to offend any of the radiologists out there who may stumble upon this blog.

Ok.

So the kid we saw in clinic last night came back this morning. He felt much better. He was playing. He was drinking. My attending decided to get a chest x-ray. The wet read on the x-ray by the radiology resident was that there was no consolidation, no pneumonia.

He still had crackles in his right lung fields, mostly over the middle lobe.

My attending and I scratched our heads for a moment, then looked at the x-ray ourselves. The right heart border on the AP projection was fuzzy, a classic sign of a right middle lobe pneumonia. The lateral projection had a clear consolidation in, you guessed it, the right middle lobe.

We prescribed another 6 days of antibiotics and sent them home.

The moral of this story is to trust your physical exam, as well as your own read on an x-ray. You are your patient's best advocate.

a teaching point

A 3 year-old came in to clinic today, referred from a family practice clinic in the area, because he was dehydrated from a presumed gastroenteritis. Here in our tranquil, sleepy town, we see kids who would normally have to go to the emergency room up in our outpatient clinic as long as things aren't too too bad. This little guy needed IV fluids, but maybe not more than that, so was triaged up to clinic.

We gave him 2, 200 cc boluses of normal saline and started maintenance fluids while we monitored his progress in clinic all evening. Even after the 2 boluses, he still looked pretty punky, not fussing too much when I would come in periodically to examine him. After he'd gotten the full 400 cc, I listened to his lungs. Lo and behold, he had crackles! He had been so dry that we hadn't heard his pneumonia. One shot of intramuscular ceftriaxone coming right up. Thirty minutes later, he looked a little better and was asking to go home, which we took to be a step in the right direction. He fussed and fought with our nurse as she tried to take the tape off his arm. Another sign that he was feeling a little better. He wanted chocolate milk, too. I mean, who wouldn't after the day he's had?

So, the moral of this story is that sometimes severe dehydration can mask a bad lung infection. The physical exam is a nebulous target that you'll miss completely if you don't pay attention. If we hadn't heard those crackles, we would have just sent him home and called it a gastroenteritis.

He'll be seen in clinic again tomorrow morning. There's no rest for the weary. Somehow, I don't mind, though, because we caught this one and know how to fix him. Even after a long day of not-so-clear-cut-cases, that feels pretty good.

the simplicity on the far side of complexity

Our grand rounds speaker this morning was Edward O'Neil, MD, one of those inspiring people who have transformed their lives in an effort to make the world a better place. His talk painted a bleak picture of the world in which we live. Poverty, war, disease, despair, apathy. Yet, as bleak as it was, it was also hopeful. There are no simple solutions, no matter what your perspective. But one person can make a difference.

I ask you...if Bono can convince Jesse Helms that withholding funding for AIDS relief in Africa is wrong using scripture, anything can happen.

I plan on reading O'Neil's two books, about to be published next month, Awakening Hippocrates and A Practical Guide to Global Health Service.

I also encourage anyone interested in global health issues to read Mountains Beyond Mountains by Tracy Kidder about Paul Farmer. Another truly inspiring individual who has changed the course of global public health.

follow-up

There has been one silver lining to this ambulatory month...the ability to schedule patients for follow-up. Usually, in our weekly continuity clinic, we hope to see our own patients for well-child care or some neat, easy-to-address-in-30min problem, like ADD or thumb-sucking. Most of the time, we end up seeing some other resident's patient and then never see that family again. This month, however, since I am here every day, all day and some nights as well, I have been able to do the quick follow-ups for sore throats, ear infections, etc. I've even been able to manage a kid with recurrent nephritis secondary to Henoch Schonlein purpura.

What the heck is that, you ask?

The short answer is that it's a systemic small vessel vasculitis, or inflammation of the small blood vessels in your body, from your skin to your intestines. No one's really sure what causes it, but it may be triggered by infections such as strep, chicken pox, or hepatitis. It usually gives you a characteristic rash on the legs/feet, as well as joint pain, abdominal pain, and blood in the urine. The blood in the urine is caused by small vessel inflammation in the kidneys, or nephritis.
Usually, it goes away in 4-6 weeks, but can recur. That's what happened with this kiddo. She had it in September, including the nephritis. Six months later, she had similar abdominal pain that prompted a trip to the ED, where they dipped her urine and found a lot of protein and a lot of blood. Recurrent HSP nephritis.

I've been able to see her twice weekly for the last 3 weeks. Once, I was unable to see her and she ended up seeing my senior resident. She thought he looked like Mr. Tumnus from The Lion, the Witch and the Wardrobe.

To his credit, his ears aren't that big, but the hair is quite similar. That, and I'm pretty sure he's not a faun. We now call her Lucy, which amuses her to no end.

That's the best part of medicine, getting to know these great kids and their families.
Next month, I go back to the inpatient floor, which has its own rewards, as well as frustrations.

bff

I returned home the other day after a particularly long day of complicated SDAs to find a belated birthday card from my best friend. Enclosed was a picture of us at her wedding, standing arm in arm as we did when we were kids.

Ever since, I have been pondering best friends and what that means. I have found that people use that term too carelessly, too superficially. A best friend is not a fair-weather friend. A best friend is not someone on your holiday card list that you think of once a year. A best friend is someone who has weathered many trials and tribulations with you. She shares your panic when you hear on the news that an escaped convict was last sighted in your hometown and races over to your parent-less house with a butcher knife...just in case. She fights with you about silly things, but is always there when you need her to ask a boy if he'll "go" with you, because she is much braver than you. She inspires you to try new things, constantly marveling at your achievements, no matter how small, and rarely acknowledging her pivotal role in who you have become.

I wonder if it is possible to form such close relationships as an adult. Or is it relegated to childhood, when you are learning as much about yourself as each other?

note to self

Note to self...never go to the market when you are ravenously hungry. No good can come of that. I now have Jalapeno Cheese Puffs, so Turboglacier better get here soon.

SDAs

Same day appointments...yup...that was my day. Here are the highlights:

1. Bronchiolitis in a 5 month old...the minute I walked in the room and heard his cough, I knew it was bronchiolitis, likely RSV. 'Tis the season!

2. Dog bite in a 2yo...they're getting rid of the dog!

3. Recurrent Henoch-Schonlein purpura with possible renal involvement...this was a tough one...spent most of the afternoon tracking down her old records, talking to her PCP and interpretting her lab results from our visit this morning...thank god for no-shows, otherwise I wouldn't be going home any time soon.

4. Diarrhea

5. Diarrhea

6. Diarrhea

7. More diarrhea

8. Vomiting

'Tis the season! Watch out for that rotavirus...

widen your circle of compassion

I had a very disturbing interaction with a subspecialist yesterday. It was my last morning on the ward for the month and I had just signed out all my patients to the new team. I get a page from this specialist about a consult I had ordered the day before. I called him back and the exchange went something like this (identifying details changed to spare the innocent):

"So, what can we help you with?"

"Well, he is an 18yo with end-stage lung disease and we were wondering if he had cor pulmonale."

"Well, how would that change his management if he were?"

"We might encourage him to wear oxygen more frequently if we knew that he was in failure."

"Does he wear oxygen now?"

"Well, yes, but not all the time. Only when he feels short of breath."

"It's a little late for compliance, isn't it?"

[an awkward pause, as I'm not sure how to respond. Finally, I say:]

"Well, we'd like you to see him and possibly get an ECHO."

"I'm just not sure what that would accomplish. Essentially, he's dying and you don't have a cure for him!"

As I reflect on this conversation, I am struck over and over by this man's callousness. In our particular institution, you have to get a cardiology consult to get an ECHO. That's not true in other institutions. Due to that peculiarity, they've developed a sense of superiority that enables them to question without impunity other specialists. Basically, a power trip.

This is a patient who IS dying. We don't have a cure for him, but that doesn't mean that we don't owe it to him to make him as comfortable as possible during the time he has left. We need to find out if he is in heart failure due to his lung disease. We need to revise our management based on that knowledge. This boy has had a hard life, beyond what most people can or should fathom. He deserves to have an easy death, to slip quietly away in his sleep without pain or worry.

We owe him our compassion.

We owe him our diligence and perseverence in finding treatments to help him.

We owe him a god damn ECHO.

In the end, I told the consultant with the sensitivity of a doorknob that my attending would love to have this conversation with him.

I am reminded of a quote from Albert Einstein..."widen your circle of compassion."

finally...

A short preamble...

During my 8 months as an intern, there have not been an overwhelming opportunity to do procedures. My first month in the ICN, I had 3 opportunities to intubate one of the little wee ones. My record was 1 for 3. Not the best. Also not all that confidence-inspiring, considering that next year, as a 2nd year resident, I will be on call without the back-up that I've had this year. During my second month in the ICN, I had NO opportunity to intubate. None. Zero. So, needless to say, I was a bit apprehensive about my looming role as a 2nd year.

I was happily minding my own business this afternoon over on the ward when the nepnatal nurse practitioner calls over and asks if I want to intubate one of the babies in, say, 20 minutes? Sure, why not. I'm 1 for 3. I'll either be 1 for 4 or 2 for 4 after it's all said and done, right?

Several, deep, calming breaths. I can do this.

I am now 2 for 4.

It went fairly quickly, although I think I initially intubated his right mainstem in my zealousness to get the tube in the right hole. Just pulled it back a smidge and, voila! Equal breath sounds on both sides. If only they were all that easy...

off-service notes

Tradition has it that your last day on service, you write a comprehensive note with a summary of the hospital course to date. So last night, while I wasn't busy with a misbehaving 28weeker who was on maximal pressors and inotropes, I sat dutifully in front of the computer and wrote detailed descriptions of what has happened during the last month.

Of course, the intern who is taking over my list on Monday likely won't even read these notes. Plus, everything will change over the weekend.

The weekend...my golden weekend...the first since the holidays. It stretches out blissfully in front of me. 2 whole days of sleeping in, seeing friends, skiing (only if there's been enough snow), and staying up past 10pm (something I try not to do when I have to get up at 5am).

Definitely no misbehaving 28wkrs. they're not allowed to be out past 10pm.