TILIR #26-30: Catch-up, part 1

Rapid-fire catch-up madness!!!

LastFridayIL: There's a 2-3 inch wide circular hole in the wall of the super secure room that houses the MRI machines that's there to allow for medications to be given to the patient

A bronchoscopy is a great way to visualize how well a jaw thrust can open up an airway. While you've already got a camera in the patient's throat, just pause a moment and pull their chin up and out. Voila! The larynx becomes twice as large. No wonder the patient can breath better when positioned properly.

Bardet-Biedl syndrome is a genetic disease that causes visual problems, kidney problems, obesity, infertility, and intellectual disability, amongst other problems. All of these widely varied effects result from a defect in the tiny finger-like cellular projections known as cilia.

LastMondayIL: ...some more basic things about manipulating IV tubing. It's amazing that no one teaches medical students some of the very basic aspects of the delivery medicine because nurses and medical assistants are nearly always the one's interacting with it. Sure, we've probably all placed an IV... once... a few years ago... but how do you flush it? How do you hook up the IV pump? How do you keep air out of the system as you hook up and disconnect various syringes.

TuesdayIL: Ketamine is a sedative that is not our first choice because it can cause kids to acts pretty crazy or aggressive when waking up. It also causes hypertension (high blood pressure), tachycardia (high heart rate), myoclonus (muscle twitching), and nystagmus (eye twitching). The blood pressure changes can actually be a good thing in patients that are hemodynamically unstable, especially since our go-to sedative, propofol, tends to cause low blood pressures, which can be very dangerous if a patient is in shock.

St. Jude's sucks at treating medulloblastoma.

WednesdayIL: CPVT stands for catecholamine-induced polymorphic ventricular tachycardia. It's an interesting if scary genetic condition where a person can be totally normal from a cardiac standpoint until they get excited or have some form of stress. Suddenly their heart starts beating so fast that it can't pump blood to the body effectively. Often people will faint as there suddenly isn't enough oxygen getting to the brain.

ThursdayIL: Delirium is much more common in ICU patients than people typically think. It comes in three varieties: hyperactive, hypoactive, and mixed. Hyperactive is what most people think of, where patients get confused, start yelling, forget things immediately, etc. But the hypoactive version can be easily confused with just sick or sedated. There is a big push to combat delirium by limiting medications known to be associated with the condition and re-establishing normal daily routines as soon as possible, even in ICU patients.

You can apparently continue sobbing while completely sedated. We had a very upset younger child that was not happy about getting the IV placed that allowed us to give her sedation medication. We took pains to make it not painful, but it doesn't matter if you're scared. When we finally just threw in the towel and went to put her to sleep, she continued to cry for nearly 5 minutes even after she was no longer conscious. T'was a little traumatic for the parents.

TILIR #24 & 25: Hearts and poisons

Wednesday morning marked a milestone for our program. It was the first multidisciplinary conference to feature a cardiac patient since we started taking care of some of the cardiac service at the beginning of the academic year.  I had actually presented a cardiac patient for one of my multi-disc conferences last year and it was noticeably difficult for our residents and even attendings to work through what was going on with that patient because we simply never saw that pathology on the services we managed. Now we are actually starting to interact with this important subset of pathology regularly and our program can only be better for it.

WednesdayIL: DiGeorge (or 22q11.2 deletion) syndrome is a genetic condition associated with numerous cardiac problems, but a particularly pathognomonic one (a symptom that is very characteristic of a certain condition) is an interrupted aortic arch. This is like an extreme form of a coarctation where the aorta not only narrows but pinches entirely off. This is obviously bad, but not immediately incompatible with life as the body will force blood through collateral smaller arteries which widen in caliber as much as they can to accommodate the extra blood flow.

__________________________

Thursday we finally got to do a well known pediatrics mainstay: baby formula taste test! A couple of the hospital's registered dieticians gave a brief lecture on the numerous different types of formulas and dietary supplements for babies and toddlers. They then lead us in groups to the adjacent room to try small samples of most kinds of formula. We of course had to run upstairs afterwards for an ice cream chaser.

ThursdayIL: Alimentum tastes like poison. This is one of the least natural formulas in that it is basically pre-digested and thus marketed as hypoallergenic (along with the other big brand version, called Nutramigen). Nearly any baby is able to tolerate this formula so it's kind of our last line of defense before things get much more difficult (IV nutrition, etc). However, these formulas are crazy expensive, very physiologically dissimilar from regular breast milk, and they tastes awful, even to babies. Seriously, though, tastes horrendous. Stay away.

TILIR #22 & 23: Gotta walk before you can... RUN! NOW!

Last Monday, I started a new block. I am trading in my collared shirt and khakis for some comfy scrubs and heading into the basement of the hospital to hang out with the sedation folks. Sedation is a weird place. It's a very pediatric specific concept where an entire department is created to provide a space for children to have minor procedures and time-intensive imaging. Most adults can handle a lumbar puncture with only local anesthetic or sitting through an MRI with, at most, a little anti-anxiety medication.

Kids, on the other hand often don't understand why they need a procedure, can't sit still enough for a scan, and have a very low pain tolerance. So most pediatric hospitals have a sedation department to help get kids through these little experiences that cause them big anxiety.

MondayIL: The Mallampati score is a way to estimate ease of intubation prior to a sedation procedure. Basically, a score of I says that you can see the back of the throat easily through the mouth. II and III indicate that you can see either most of or just the base of the uvula (the dangly thingy in the back of your throat) respectively. IV means the patient's mouth shape and tongue size make seeing the throat very difficult, and accordingly, they would be a more difficult intubation.

Another metric we use is the ASA (American Society of Anesthesiology) scale, which categorizes patients by how generally healthy or sick they are:

• ASA I - Healthy
• ASA II - Mild sytemic disease or major disease under good control (mild asthma, cancer in remission, etc.)
• ASA III - Major disease/illness, not controlled (influenza, cancer not in remission, etc.)
• ASA IV - Major disease/illness that is a constant threat to life (ICU patients)
• ASA V - Unstable patients that will die without the procedure
• ASA VI - Brain-dead patient awaiting organ donation

Well that escalated quickly, huh?

________________________________

On Tuesday I got to experience a bit of the sink-or-swim method of teaching. The physicians that administer monitored anesthesia care (MAC) (formerly known as conscious sedation) in my hospital are all pediatric intensivists (ICU doctors). As this level of sedation is by far the most common in the sedation unit, it's most of what I get to see. After one day observing various intensivists administer sedatives, generally in the form of Propofol +/- Fentanyl, I was getting somewhat comfortable with the procedure of "pushing meds," as they call it.

On day two, I was rushing out of one procedure and into another for which sedation was being provided by an attending I had yet to work with. I walk into the room, apologize for not being there at the start, and am immediately beckoned over to the head of the bed. 

"This is what, your second day?" asks the intensivist. 

"Yep!" I assured him. 

"And you've been pushing meds, right?" 

"Nope! Not yet!" I reply nervously. 

"Well, there's no better time to start!" he says without missing a beat, and hands me the syringe of death milk (it's white and opaque, much like milk, actually for the same reason as milk (it's a colloidal suspension)).

While this may seem horrifyingly reckless, it's a good bet that a nervous resident is going to err far on the side of pushing too little anesthesia than too much. And in fact, that first time, I didn't push a single milliliter of sedative without the attending telling me to.

TuesdayIL: If a patient's oxygen saturation starts plummeting during a procedure, there are several things that can be going on. First, check that the pulse ox sensor is actually still on their finger. Of course they'll have a low reading if the little red light isn't shining through their finger/toe/earlobe/etc.

But say it's real. The patient's oxygen saturation actually is plummeting. What's happening and what do you do? The two most likely answers to what's going on are that:

a) you pushed too much medication and now they aren't breathing, or
b) something irritated the middle part of the throat (larynx) and the patient is trying to breath, but can't because the airway is spasming closed.

So, what do you do? Actually the exact opposite thing. In the first case stop pushing sedatives. You also may need to put a mask on them and bag a few breaths until they start breathing on their own again.

In the second case, it's far easier. Push more sedative medication, and quickly. This will relax those spasming muscles and allow air to pass again.

TILIR #21: No more, fingers crossed

[A little behind, but I'm taking notes and will catch up over the next few days! Sleep is sometimes more important than blogging (gasp!)]

On Sunday I had to go into the hospital for the the first part of the last 24 hour newborn call shift my program will ever have. They recently changed up the distribution and responsibilities of senior pediatric residents at my program. We used to have a rotating call pool that had to takeover the newborn nursery service a few weeknights for a month at a time and then work at least one weekend 24hr call shift, all while on another rotation on weekdays. Now, one of the inpatient senior residents will always take call overnight.

Anyways, I had to go in at 7am to round on a handful of babies with the attendings who were working that day. If, from 7am to 7am the next day, there were any calls on any of the ~30 babies (a very below average number), I got the page and either took care of the problem or asked the on-call attending for help. Was actually a pretty mild day/night. My biggest gripe is of being notified way after I should have been about a problem. I can't fix a problem I don't know about and sometimes I can no longer fix problems that I hear about too late.

SundayIL: Syndactyly, or webbed and conjoined fingers and toes, is surprisingly common. It's often easy to fix at a very early age, which is why you don;t see many adults walking around with double thick fingers or flipper feet. But what may not be obvious is that conjoined fingers are not caused by fingers getting stuck together in utero, but rather because a part of our embryonic flippers fail to separate.

There are numerous inheritable forms of syndactyly and it is associated with many different genetic syndromes. Without other findings, however, it's not really worth it ot do a big genetic work-up on a baby with a few conjoined toes and fingers. Have orthopedics fix them (or not) and just let them go along with their lives.

TILIR #19-20: Tenacious D

Today we had a set of parents come in to their pediatrician with their newborn. We talked about vitamin D supplementation while breastfeeding, among many other things. They remember their older child taking the older version of this medication that came as a liquid with a small dropper to dispense the not-insignificant volume of medicine into the baby's mouth. It wasn't much fun because it tasted bad and babies tend to spit it out. But thankfully the newer preparations of this supplement are concentrated enough that you only need one drop.

So, we turn to mom and explain that the easiest way to give the medication is just put a drop on the breast before a feed. Simple!

Dad chimes in: "So you just spread it across the baby's chest like a VapoRub?"

Mom shoots him a looks that plainly says, "Are you an idiot?" But the other doctor and I laugh and explain that, no, the drop is placed on mom's breast so that the baby swallows it when breastfeeding.

ThursdayIL: There is a charter school near the airport in Grand Rapids called the Aviation Academy, where kids who want to be pilots (or just get a really STEM education) can go to high school instead of a normal public high school. Weird niche schools like this are touted as examples of how charter schools (the pet project of our Grand Rapids native Secretary of Education Betsy DeVos) can expand the model of public education.

However, I'm less impressed with the system when I see kids from other charter schools that are falling behind without repercussions thanks to loose regulations. And when resources that should be helping all public schools provide a great education are diverted to niche elite schools like the Aviation Academy, it makes me sad. Strangely enough you don't see many of the inner-city population that I tend to see in my clinic attending the Aviation Academy.

TodayIL: If you are testing an eye for HSV or chlamydia (as are concerns in a newborn with a red, swollen eye) you need to culture the eyelid not just some eye discharge, because both of these organisms are intracellular. There aren't any skin cells in tears or eye discharge, so you need to scrape some off the interior of the eyelid.

If a neonate does develop a suspected chlamydial infection of the eye, you should always treat it with systemic antibiotics, rather than with just eye drops. This is because the other major area where neonates can get chlamydia is in the lungs as pneumonia. If they were exposed in the eye, they were likely exposed in the lungs, so treat now regardless of respiratory symptoms and avoid the dangerous sequelae of a newborn with pneumonia.

TILIR #18: Ota, Ito, and blue milk

Blue flour-water
from Wikipedia

TIL: Nevus of Ota and nevus of Ito are two lesser know types of dermal melanocytosis, or gray-blue patches of skin. The more common form is the gray birthmark often found on the lower back or butt called congenital dermal melanocytosis, but more commonly known as Mongolian spots. The medical field is trying to shy away from this latter terminology... in case it offends Mongolians? It's not good or bad so not sure why it would offend. I think it might be more that the name is just arbitrary and inaccurate, with the condition having nothing to do with Mongolia or its people.

Anyways, nevi of Ota and Ito are gray-blue patched of skin in the distribution of the first/second branches of the trigeminal nerve (top half of the face) and the posterior supraclavicular and lateral brachiocutaneous nerves (neck, upper arm, upper back).

The Tyndall effect is what gives these lesions a bluish hue. This is the same effect that gives rise to blue eyes and turns milk with flour in it blue. In the milk, flour particles scatter light with the energetic blue light preferentially scattering over the red wavelengths.

In both eye color and the above skin lesions, the flour-like light-scattering particle is melanin, the dark pigment that colors skin. The bluish gray skin color with any of the dermal melanocytoses happens just like the blue milk, with melanin scattering the blue light and absorbing the red. Eye color is far more interesting. Irides with lots of melanin absorb almost all the light coming in because any blue scattered light from all but the surface-most layers of the iris just get caught by the melanin in front of it when trying to bounce out. These eyes tend to look dark brown.

Iris color diagram (made by me!)

The less melanin in the iris, the more blue light is able to escape back out of the eye after scattering. Bright blue eyes have the perfect goldilocks amount of melanin to scatter light but not get in its own way. Greens and hazels are somewhere in between. Albino persons have no melanin in their iris and so neither absorb nor scatter light coming in. The iris is basically see-through so the red of the retina behind can shine through giving the appearance of red eyes.

TILIR #17: Balto and diphtheria serum

One of the attendings today was opining about how flippant parents have gotten with vaccines now that most of the diseases that vaccines prevent are rarely if ever seen anymore. However, she has been practicing so long that she can pull stories from her own experience of most of the diseases. She's seen many kids die of the various types of meningitis that are basically nonexistent in the US. She's seen measles, mumps, rubella. Rotavirus used to be everywhere. The list goes on and on. However, she does admit that there are a few diseases that were gone even before her time. Polio is the first, but thanks to FDR and the countless other survivors, everyone still remembers the horrors of that disease.

The statue of Balto in Central Park, NYC

Diptheria is the second. But, unlike polio, people don't remember this nasty respiratory illness. So the example she used is actually the story of Balto, the Iditarod husky. The story was popularized (and heavily fictionalized) during my childhood by the animated movie named after the real dog.

The real tale is of the famous passage of a series of dog sled teams along the harrowing Iditarod trail to deliver diphtheria serum to Nome, Alaska during an major outbreak of the disease with a blizzard blocking any other transport by air, train, or sea. Diphtheria toxin consists of antibodies against the bacterium, and was the only treatment at the time.

Nowadays no one training in medicine in the US has even seen a case of diphtheria thanks to vaccination. There were 5 reported cases in the US in the past 10 years (compared to over 1700 cases of the measles and well over 100,000,000 cases of the flu).

TILIR #15-16: Hi, I'll be your backup doctor today!

Over the past few days, I've had the interesting job of picking up extra patients at the pediatric office I'm working at this month. Between vacations, maternity leave, and cushy workloads, there are more patients to see than doctors available to see them right now. I am *technically* a doctor, so I can see some of the sick kids that we would otherwise not be able to fit in between all the previously scheduled well-child visits.

I swear they initially gave me stupidly not-sick sick kids to see, just to test my basic competence. I appreciate this because just navigating their electronic medical record is a nightmare. 

Me: Using my amazing doctory skills, I have determined that your child clearly has an ear infection!

Parent: Great! Now what?

Me: Now, I would normally send a prescription to your pharmacy...

Parent: Ok...

Me: But I need one of the nurses to send it under the name of one of the other doctors, so I'll send an electronic message and.... well, drive slow or get lunch before trying to pick it up.

Parent: Thanks?

For some reason, I still make appointments disappear on the digital schedule anytime I open them on the computer. No one knows why. Also I'm positive I have been coding things incorrectly, but the office has a person whose whole job is to fix coding, so hopefully it hasn't been a real issue.

But parents and patients are truly very grateful that they were able to be squeezed into the schedule even if only to see me, rather than have to wait days for an acute visit spot with one of the main doctors. So that's cool, I guess.

FridayIL: While staples aren't supposed to hurt to remove, if you put a million of them in long-haired scalp and let lots of crusty, bloody scab form around them, they sure will sting a bit.

TIL: Gianotti Crosti syndrome is a blistering rash that forms on the arms, legs, and buttocks. The rash develops after separate infection with one of any number of viruses. The big viral culprit used to be hepatitis B, but since widespread vaccination has greatly reduced those infections, the Epstein-Barr virus (EBV) has taken up the mantle as the primary cause. Many other viral illnesses have been implicated as well, but less often.

Sialadenitis is the fancy medical word for inflammation of any of the salivary glands (parotid, sublingual, and submandibular) in the mouth.

TILIR #14: Hard questions

Today was our first weekly Thursday lecture of the academic year. It's a 4 hour block of "protected" time, where we theoretically shouldn't need to worry about any clinical duties and can give our full attention to learning. What this really means is people should stop calling you at noon (when the lecture time starts), but then you catch up with your work as fast as you can before grabbing lunch and heading downstairs to the conference room. 

At the beginning of the year we split up for the first hour, with the interns getting a series of lectures about hospital/residency basics and the senior residents doing practice board exam questions. Then we meet back up and have three traditional lectures. The topics are usually coordinated, such that there is a rough theme, e.g. eyes, kidneys, vaccines, etc. 

Today's topics were ethics and safety. Medical ethics is always difficult, but pediatrics brings in a few new levels of complexity. For instance, part of the discussion today was about informed consent and refusing care. Can a 17 year old refuse a blood transfusion? Probably. Can parents of a 2 year old refuse giving her chemotherapy for a very curable cancer? Nope, definitely not. But what about a 10 year old who doesn't want any more chemo after their cancer comes back? Or a 17 year old that doesn't want to treat their HIV? Are you willing to tie them down to force medication in them?

TIL: Baby Doe rules are dumb because, unsurprisingly, politicians are awful at writing medical ethics rules. These are ethical rules written under the Reagan administration in response to a controversial case of withdrawal of care for a newborn with significant congenital anomalies. Under the rules, withholding treatment from any newborn is only permissible if the child is irreversibly comatose, if treatment would only prolong its death, or if treatment would be inhumane.

Any of these conditions seem reasonable on the surface, but pretty quickly you can see that this standard doesn't hold water. For example, nearly any treatment is only prolonging death; that's basically what medicine is. And what is defined as inhumane? To whom?

TILIR #13: Heart plumbing repair

Today instead of our usual Wednesday morning multidisciplinary conference ("multi-dis" for short),  we had a case presentation and lecture by the scary-smart Chair of Pediatrics for MSU. This guy always manages to have the most interesting cases. These are stories that twist and turn in unexpected ways en route to weird zebra diagnoses. The Powerpoint slides tend to be punctuated with vacation pictures from all over the world, which is nice too.

TIL: The Mustard procedure is the older version of surgical repair for the congenital heart defect of  transposition of the great arteries. This is when a child is born with the aorta and pulmonary artery switched. This is not compatible with life after the in utero blood circulation pathways close, so an emergent surgery needs to be done after birth.

Nowadays, the surgery simply consists of chopping the two vessels off at the top of the heart and swapping where they attach. The tricky bit is that the coronary arteries, which supply blood to the heart muscle itself, must be carefully repositioned. This is so difficult that before modern techniques were developed, surgeons would instead reroute the blood within the heart.

Think of a washing machine. Imagine that you accidentally hooked up the hot water to the cold input and the cold to the hot. Because of some goofiness with the hot water pipe, rather than switching the two hoses to where they should be, you instead opt to open up the washing machine and rig up a series of spouts and PVC pipe that directs the various temperature water to the right end point. 

It's shocking that this worked, but it was both the standard of care and the only option for a long time.

TILIR #12: Old tests and new tests

I started today out with a bit of a shock. Turns out my second in-training exam (ITE) was scheduled for this afternoon. This is an annual practice test that is given in any residency program to monitor how each resident is progressing towards being able to pass their board exam. I first took this 3-hour multiple-choice test last summer a mere 2 weeks into residency. The nice part of that first sitting is that there is no expectation that you know basically anything... yet.

But a year in, we are actually judged against each other and our prior selves. Today felt better than last time; I definitely knew more. But I was still doing a lot of shrugging and guessing. ***As a reminder, these tests are designed to be exceptionally difficult and borderline unfair. It is not a measure of your ability to do the basics of the job, but of your mastery of the trickiest elements of your chosen field. Sucking at this exam, does not mean we are bad doctors in our current roles.***

Between remembering that I had an exam and taking said exam, I had another small milestone of seeing patients by myself in the private pediatrics practice I'm working in this month. The whole office is super grateful when residents do this, especially when multiple of the normal docs are out of the office. It is a little intimidating for us though. First of all, they use a different electronic medical record than the hospital. Second, the parents, while happy to get a same day appointment, are usually expecting to see one of the veteran practice partners rather than a green-behind-the-ears resident.

TIL: Hair grooming syncope is a condition that can happen, typically in girls (because of the societal norm of girls having longer hair, not for any biological reason), where a child can faint if their hair is combed, brushed, and/or pulled tight. You can minimize the risk of this or any other fainting with adequate hydration and electrolyte replacement.

TILIR #11: A very autoeczematous day

Today was a weirdly well-bookended day. It was the first morning report of the new academic year. This is when all the available pediatrics residents, attendings, and medical students meet in a conference room for half an hour for a presentation by a senior resident. The subject matter is an interesting or informative patient case paired with some brief teaching on the associated topic.

Today's was a case of poison ivy with an academic bonus nugget about autoeczematization. I immediately noted that word down to be the topic for my "TIL" fact of the day. I put it out of my mind and went about my day.

I had a full day at the outpatient pediatrics office I'm stationed at for the month. The very last patient of the day was a sick visit with a chief complaint of a rash. After maybe 10 seconds in the room it was immediately apparent that he had a case of... you guessed it... autoeczematization.

So, without further ado:

TIL: Autoeczematization is the development of a generalized rash that is removed from the inciting event by location and/or time. For instance, a person can get a small patch of poison oak on their arm, but then a few days later develop a different, eczema-like rash on their chest, abdomen, face, and legs.

In an autoinflammatory process, the body tries to target the insulting foreign substance but accidentally targets damaged parts of the skin found in the same area. The immune system then seeks out these skin structures and causes a rash all over the body (since there is skin everywhere). Worse yet, the rash is itchy, but any itching just releases more of the mistaken skin target structures for the immune system to attack, resulting in even more rash.

TILIR #9-10: Feast and famine

Some days is truly difficult to come up with a single concrete thing that I've learned. I'm obviously still learning how to be better at my job, how to be more efficient, how to play nice with others, etc. but rarely can those intangibles be made solid enough to write about. That was Thursday; I had to scrape together a tidbit about a rare disease that I just don't know as well as I should.

Friday I was working with a different doctor and our patient mix just happened to lend itself to a veritable deluge of teaching moments. Buckle up! I promise most of them are pretty interesting!

ThIL: Ehlers-Danlos syndrome is a condition marked by too much elasticity - of the skin, of the joints, and (here's where we get into trouble) of the walls of some blood vessels. There are currently 13 subtypes of this syndrome, varying by different presentations. For instance, there are some subtypes that also have eye problems (known as "brittle cornea syndrome"), and others that have bony changes including bowed legs and scoliosis. Unsurprisingly, there are many different genetic mutations that can cause this condition.

FIL:

• Grand Rapids was where the first pertussis (whooping cough) vaccine was developed. In the early 1930s, two scientists by the name of Pearl Kendrick and Grace Elderington did basic research to help learn about the disease and then developed a vaccine. Most vaccine testing at that time was done on orphan or institutionalized children because it was easier than convincing parents to test a vaccine on their children. But Kendrick and Elderington built a coalition of health department officials, doctors, schools, and parents in Kent County to trial the vaccine on a diverse group of kids from throughout the community. These two women should be as well know as Salk who developed the polio vaccine, but they always refused publicity despite saving untold hundreds of thousands of lives.
  
• There is a newly approved treatment for hyperhidrosis (sweating a lot (like a lot, a lot (like your-hands-are-always-dripping-and-your-shirt-is-never-dry a lot)). It's a topical anticholinergic, which is great because you get all the benefits of the systemic drug with far fewer side-effects. Up until now, we basically had intense powered antiperspirant or an invasive neurosurgical procedure to cut the nerve chain that controls sweating.
  
• A halo nevus (aka leukoderma acquisitum centrifugum 'cause dermatologists are horrible) is a mole that the body eats from the outside resulting in a progressively shrinking dark spot with an inwardly thickening ring of light skin. The mole disappears pretty quickly and then the white area gradually fades. It's nice to have an immune system that will attack moles, however it comes with a risk. These same antibodies that attack the pigment cells of the mole can sometimes go crazy and attack all the pigment in all of the skin, leading to vitiligo where large patches of skin will turn stark white.

  

  A rough diagram of the progression of a halo nevus

• Singulair (montelukast) is a common asthma medication of the leukotriene inhibitor class. It actually has a competitor that isn't used very often called Accolate (zafirlukast). I had never even heard of it. It's probably less well known because it must be given twice a day rather than one a day, and it is significantly more expensive (not that Singulair is all that cheap anyway).
  
• One "small" section of the large ethnically Dutch population in West Michigan is the Frisians. They originate from the Friesland province in the Netherlands, which is the only province to have it's own language and is historically known for the exceptional height of its population. This does throw a kink in using US national averages for growth charts during well-child visits. Telling someone he is at the 60th percentile in height nationally is awfully misleading, since in certain high schools he is likely one of the shorter guys in his grade.
  
• Paroxysmal kinesigenic dyskinesia is a very rare neurological disorder that actually describes itself fairly frankly (for medicine). Symptoms consist of occasional weird movements caused by quick, voluntary movements. For example, jumping out of bed can trigger dance-like movements of the legs. There are some antiepileptics medications that can lessen the frequency of episodes but eventually, most people just grow out of it over time.
  
• And then finally we have something that, confusingly, I learned through fact-checking for this blog. Or rather, I learned that I already knew something and that my attending was trying to teach me something incorrectly. Prolonged use of a pacifier, continued bottle-feeding, and thumb-sucking do indeed have long term effects on orthodontia. Word to the wise: if someone tries to teach you something by prefacing with "just think about it..." instead of "studies have shown...," be dubius.

TILIR #8: The Clinic Strikes Back

Today was my first day of clinic since becoming a second-year resident. A lot changes from the first week of first year to the first week of second year in regards to our clinic workload. Initially we don't have much idea what we're doing, both in terms of general logistics, navigating the electronic medical record, and - ya know - practicing medicine. It is, after all, a somewhat shocking experience to suddenly be the primary care provider for children.

We start out with only one patient for an entire morning or afternoon shift in the clinic. By the second week, we are up to two patients and it stays there for a couple weeks. After that for morning clinic we see three patients and afternoon clinic we can see up to four. As second year however, we have clinic all day long, and we also increase the number of patients so we can see up to four in the morning and 6 in the afternoon. All of this means we have to be more efficient with our time or we end up having a lot of extra work at the end of the day to catch up on.

One of the more fun things that I got to experience for the first time today was working with the new interns (the first-year residents). Since I've been on an outpatient rotation the rest of the month, I haven't actually gotten to work with any of them since seeing them throughout their orientation. It was nice little dose of schadenfreude seeing these scared new doctors figure out the ropes. As we helped them throughout the day, it was a pleasant reminder how much my classmates and I have grown in the past year.

TIL: There is an old psychiatric diagnosis called the Cotard delusion or "Walking Corpse Syndrome." It is no longer a official diagnosis in the DSM-5 (the official diagnostic manual of psychiatry), but I stumbled across an old ICD-9 code in the computer for this diagnosis and I just had to look it up. Seems the vague idea used to be that this particular delusion was that the patient believed that their some or all of their body was dead or decaying. Descriptions are rather vague though, and with such a broad grouping of delusions it makes sense that they were just lumped into other somatic delusions.

TILIR #7: Got an itch

I feel bad having been assigned to my current rotation site. It is a wonderful outpatient pediatrics office. Stellar doctors, great staff, lovely patients and families. About half of my program wants to go into general pediatrics and would kill to rotate here. It's the sort of place that you would dream of someday working at. 

I am so bored! Today I was working with my favorite attending, who is 30 years my senior and yet I feel like we could be best friends. But every patient we saw was either totally healthy or had super non-specific symptoms that we had to basically say we'd wait and watch. I want to see sick kids!

Don't get me wrong; it is a very relaxed rotation. I get to work around 9, get over an hour for lunch and am done by around 5:15. But I know many residents in my shoes would come in early to see more patients, or rush to try out the electronic medical record, or see patients on their own. I like hanging out with most of these attendings, but mostly just want to be done with this rotation. The grass is always greener, I suppose.

TIL: Sand fleas are tiny crustaceans than can cause small itchy bites on the skin. Rarely, certain species will bite the skin and then burrow into it to give their eggs time to mature and hatch. Seriously! There isn't really anything to do from a medical perspective but wait and treat the itchiness.

The beach and TILIR #6: Putting a name to it

Yesterday, Jenni and I jumped in to the typical Michigan activity of... going to the beach! As a California native and former bicoastal resident, I never associated Michigan with sunny, sandy beaches. Snow: yes. Cars: sure. Beaches: not even in my top 10 beachy states.

The path to our secret little beach
on the coast of Lake Michigan

But it turns Michigan with it's two enormous peninsular halves, is chalk full of beautiful beaches. Bordering four of the five great lakes will do that. And while it is pretty chilly and snowy in the winter, it's fiercely hot and humid in the summer.

The waves aren't much to write home about, but the water isn't salty, the sand is clean (due to the dearth of both plant life and petroleum wells), and the water level stays the same (no tides). There are giant state beaches that thousands of Michiganders flock to each weekend, as well as tiny off-the-beaten-trail beaches that are quieter and more intimate. Yesterday, Jenni and I ventured to one of the latter and had a wonderfully peaceful time.

TIL: Pleonasm! You ever know that feeling that there must be a word for a thing but you neither know the word nor how to describe it well enough to find the word?  Well a couple months ago an attending and I were (apparently) trying to think of "the use of more words or parts of words than are necessary or sufficient for clear expression: for example black darkness or burning fire."¹ The best we could think of was tautology, which does have one similar definition, but I mostly hear tautology used in the context of logic, which is a subtly but distinctly different concept.

And, just to make sure a dab of medicine ends up in this post: I also learned that we don't have a great idea how many kids "grow out" of ADHD. Somewhere 15 and 50% of ADHD patients no longer qualify for that diagnosis by their mid 20s. However a significant portion of these young adults are able to be reclassified as having other behavioral concerns such as an autism spectrum disorder or anxiety.

TILIR #4-5: On call

Oof. That was painful. So painful it took two days to recover enough to post this.

Last night I took call for the first time in my medical career. There's some confusing nomenclature here. When we cross-cover and work in the hospital over a weekend, we sometime refer to those shifts as call shifts. If we are working nights, then we might get Monday off because we are "post-call."

But what I did last night was more of what the average person thinks of as being on call. I was at home. I had a phone. If anything happened in the hospital's newborn nursery and required a doctor, they called me. If I can handle it from home, I can give advice or put in orders from my computer. However, if a baby were sick enough, I would have to throw on some scrubs and drive in.

As is often the case in medicine, this could result in wildly different nights for me. Either I get a couple of calls but otherwise a pretty normal night's sleep, or I'm basically working a full night shift between two normal day shifts. There is a rule in place that if you have a rough night, you can ask an attending physician to excuse you from your morning clinical activities to get some sleep. But we try not to use that excuse unless we really have to.

Last night I got 7 different calls, plus two other times I got up on my own to check on a lab result. I  slept maybe 5 hours but broken up so that the longest stretch was a little over an hour. I was so tired today that, for the first time since my surgery rotation in med school, I briefly fell asleep standing up. 

It's neat that I have advanced enough to be trusted with this responsibility. But if I'm going to stay up all night, I think I'd rather it just be in the hospital working. Thankfully, most of my top choices for careers after residency, do not include home call.

YIL: There is no current treatment for RSV infections other than supportive care, but there used to be. Ribavirin is an antiviral chair used to treat numerous viral diseases including hepatitis C, various viral hemorrhagic fevers, and, until recently, RSV. Studies done on the drug showed that it was not super effective at decreasing symptoms or hospital stays due to RSV, it was crazy expensive, and there was some concern about occupational exposure to nurses, with this drug having some association with birth defects in pregnant women. The big factor however, seemed to be the extreme cost for little benefit. It is still FDA approved, but only rarely used for immunocompromised kids with known exposures to RSV.

TIL: Adenovirus is the main virus being researched for use in general therapy. It was picked because it is one of the few viruses that targets multiple, disparate organ systems. Unlike for example RSV which targets the lungs and airways, or rotavirus which goes after the GI tract, adenovirus hits both those major systems plus smaller ones like the eyes. The biggest hiccup in this plan is that it has proven really hard to separate the infectiousness of the virus (which we want) from the pathogenicity (which we don't).

West Michigan Fourth of July

The Fourth of July in Michigan is weird. Well, it's probably totally normal to everyone around here, but to a fella that hails from both coasts, this is all wrong.

First of all, fireworks are legal here. Neither of my previous home states had legal fireworks. Of course people smuggled them in pretty easily from neighboring states but there was an exciting naughtiness to seeing any elicit fireworks go off in your neighborhood. I once played with a sparkler that was smuggled into California from Arizona. It was thrilling!

In Michigan, not only are fireworks legal, they are ubiquitous. There is a pop-up tent in every parking lot selling arsenals of near-professional grade pyrotechnics. Around here, you are only supposed to set off fireworks in the few days before or after a relevant holiday. You might hear a couple distant pops and crackles in the week leading up to the Fourth, but once the sanctioned timespan begins, there are multiple large fireworks going off every second in every direction for a good three hours per night, with aftershocks of drunken shenanigans through 3am.

Last year, Jenni and I were living out of a third floor room in an extended-stay hotel during the Fourth so we had a great view of the dozens of private little fireworks shows going off at any given time stretching out to the horizon.

But the more annoying difference with fireworks here, compared to other places I've lived, is the time it gets dark. West Michigan is way over on the extreme western end of the eastern time zone. Between that and our modestly northern latitude it means that in early July, sunset isn't until 9:30 and it isn't dark until about 10:30. When you work early the following day, how can you stay up for that?! Little kids stand no chance of staying up for a fireworks show.  And if you do decide to just go to sleep, you're bound to be woken up repeatedly when your neighbors decide to fire off their own private artillery barrage 20 feet from your bedroom window.

I love fireworks, but I long for the relatively subdued and controlled celebrations of some of the other, more sensible places I've lived. Ah well, here's to the wild freedoms of 'Murica.

TILIR #3: Mentors

Through the course of my medical career, I've met and worked with many very talented and  accomplished doctors. The old adage of "those who can't do, teach," does not generally hold up in medicine. In pediatrics, mediocre physicians can plod along just fine in an urgent care or private office, but if you're teaching medical students, residents and/or fellows, you need to be on top of your game. We question everything and have the entirety of medical literature at our fingertips via our phones and computers.

What we are really hoping to glean from our mentors is the wisdom and experience that is more difficult to codify into guidelines and algorithms. Some of our younger attendings seem to know every relevant paper published in the past 5 years in pediatrics, no matter how obscure. But some of the older attendings can reliably call that a seemingly stable patient will be in the ICU by morning just by glancing at them. The former talent we can learn from reading books and going through practice questions, but the latter just takes time and purposeful observation.

Today I got to work with another one of those mentors that simultaneously make me proud to be in this profession, afraid that I'll never be good enough, and hopeful that someday I might be. It's remarkable how much has changed since her generation of physicians were in my position. The hospital here in Grand Rapids only had a couple pediatric floors, the residency only had a quarter the number of residents, the residents drew their own patient's blood, there were no intensivists or neonatologists on call overnight, and they saw countless children hospitalized or dead from illnesses that we never even see today thanks to vaccines. I often wonder what medicine will be like 30 years down the road when I have been practicing as long as she has.

TIL: Stickler syndrome is one of the broader constellations of symptoms that includes the Pierre Robin sequence. Pierre Robin (pronounced "Pee-air Row-ban"), consists of a small, receded jaw, protruding tongue, and cleft palate. It is non-specific and can have numerous causes and several distinct associations. With Stickler syndrome, the Pierre Robin findings are joined by hearing loss, arthritis, severe myopia, and retinal detachment.

TILIR #2: The game plan & clock management

Today was my first official shift as a second year. I am not in the hospital today, but actually at a private outpatient pediatrics office in my neighborhood.

My residency program is three years long, with each year composed of 13 four-week blocks. During our first year, there is a pretty rigid set of rotations including 4 of inpatient floors, 1 NICU, 1 newborn nursery, 1 ER, 1 heme/onc, 1 advocacy (including child abuse), and 4 electives. The order is almost random and you can have pretty rough stretches and other rather pleasant periods.

For our second year, we have a little more flexibility. We choose one of a handful of tracks that somewhat tailor our schedule to match our professional aspirations. In my case, I'm thinking of doing critical care so my schedule is stacked with an extra PICU block, a sedation rotation, and a "skills" block where we get to practice minor procedures.

This month, however, I am doing one of my required rotations in a nearby pediatric office. The idea is to give us some exposure to an outpatient setting on the other end of the spectrum from our resident-staffed clinic. Whereas we generally see an urban, poorer population with several barriers to care (transportation, insurance, parents that work multiple jobs, single parents, foster parents, etc), Most of the pediatrics offices in the surrounding suburbs have patient populations that have fewer problems. Patients tend to show up on time, they tend to actually take their medications as prescribed, and they call the office frequently instead of visiting the ER for minor issues.

It's a very pleasant rotation, by all accounts. 

TIL: There is some evidence that probiotic drops can help some babies with colic (unexplained fussiness and crying greater than normal). These are different than the old simethicone "baby drops" that used to be given out to theoretically combat gas. In reality, they had no greater effect than a placebo. Probiotics have a greater effect than a similarly administered placebo, but placebos work pretty well too. Half the battle is just running out the clock until this condition resolves on its own between three and four months of age. 

TILIR #1: Another July 1st

Hello internet! It's been a while since we talked. Since the last time I wrote, I finished up medical school, matched into Pediatrics, moved from the Bronx to Grand Rapids, and completed my entire first year of residency. As of 0700 this morning, at the end of a long night shift, I signed out my team's patient's to the new interns and officially became a senior resident!

Sleepy me having celebratory brunch

Residency traditionally begins on July 1st, a notorious date, when every provider you meet in the hospital effectively becomes a year less experienced. For historical reasons, the first year residents are known as "interns," as opposed to senior residents, or "seniors" for short. The intern is likely the first doctor you see in a teaching hospital and also the doctor you see most often.

On the morning of June 30th each year, that doctor has been practicing for 364 days - not a whole lot by any means, but with 80 hour work weeks and only a few weeks off a year, they have gained an enormous amount of practical experience since graduating medical school. On the morning of July 1st, the first doctor you see has zero days of practical experience outside medical school. Sure, they've done some "sub-I" (sub-internship) rotations in medical school where you get to go through the motions, but they haven't so much as ordered Tylenol. This is likely their first day using a new computer system. Imagine if your first day with a new piece of technology had children's lives riding on your ability to use it effectively and efficiently. Everything is going to take at least twice as long to accomplish, even with double the supervision for the first few days.

But it's not just the new interns that are dangerous; with each new academic year there is suddenly a new group of supervisors. As an intern, you are one of many on a team. You do the grunt work of writing notes and putting in orders. But every team has a supervising senior resident. Unlike most jobs where you can either aspire to a management position or not. All doctors must lead teams during their training. And we're not all good at it.

So, on July first you have teams of newly minted doctors being lead by often first time leaders. There are, of course, very experienced attending physicians watching over everything, but they can't be everywhere at once. So, avoid the hospital, if you can, for the next few days. We're all climbing that steep learning curve, but we'll be with you shortly.

TIL: Rett syndrome is a rare genetic condition that almost exclusively affects girls and causes progressive developmental regression that can be stabilized but not reversed with symptomatic treatment. Rett syndrome is caused by mutations on the X chromosome of the MECP2 gene, but we don't know exactly how errors in this gene cause the symptoms of this disease.