TILIF #14: Boardom

One of the many strange things about medical education is the seemingly random interval between the various standardized competency exams that you take along the way to becoming a fully licensed, board-certified physician. For example, your medical licensing exams happen in four parts: the first after two years of medical school, the next two after the third year of medical school, and the final test is taken up to a year after you've completed medical school. From there, the next big hurdle is becoming board certified by whichever medical board oversees your residency. Completing this signifies being able to practice independently in your chosen field. But some specialties have a multi-step board exam just like for medical licensing while others just require that you take your boards at some point following completion of your residency training.

The American Board of Pediatrics, for which I have recently become board eligible, gives us seven years post-graduation to take our board exam which is held on every year in mid-October. Generally, everyone aims to take the exam as soon as possible (so three months after graduating from residency), to allow the least time for forgetting the sorts of minute details that are ingrained into you during residency for this exam but that will rarely if ever come up during your day-to-day practicing of either general or specialty pediatrics. For most people, this means dedicating as much as possible of the three months after graduation to studying. If you're going into private practice, you might ask for a delayed start time or a extended vacation to properly prepare. If you're going into fellowship, most programs will allow for a lighter schedule during this time so that you can get this test out of the way and concentrate the remainder of your fellowship time on mastering the more specialized knowledge of that field.

Unfortunately, I have picked one of the very few fields where the luxury of taking it easy for a few months is not entertained. Pediatric critical care programs are easily some of the most clinically heavy fellowships out there. Most other fellowships expect you to spend approximately two of your three years on research projects to better establish yourself in the field and add to the collective knowledge of the discipline. In the pediatric ICU, we spend roughly 18 of our 36 months on service in the ICU, pulling 12-13 hour shifts with the occasional 25-hour in-house call.

In regards to this, I've been given some rather frustrating advice. Somehow I'm supposed to focus as much of my energy as possible on passing boards during these first three months. But I'm also trying to navigate that steep learning curve that comes with being immersed so fully in this completely new level of care. Thankfully there are pretty low expectations for a new fellow in regards to both knowledge and skill, so, if I don't mind playing the fool, I can coast on my current ineptitude until November. The real problem though is that the work that we're trying to do is to take care of very sick children, so giving it any less than your all really doesn't feel great, even if there are many other people to pick up the slack.

Rant over. I know it's not all that bad. I'm pretty sure there's a way to strike a reasonable balance; I just don't like to multitask in that way at work. Hopefully I figure it out soon!

TILIF: Thrombopoietin mimetics, are drugs that mimic the hormones that stimulate the production of platelets.

A "walking taco" is apparently a midwestern state fair and tailgating staple that involves taking a bag of nacho cheese Doritos or Fritos and pouring into it your favorite taco toppings. This makes it easy to carry one-handed, leaving the other hand available for an alcoholic beverage.

Elastance is a totally made-up-sounding word that means the opposite of (or, mathematically, the inverse of) compliance.

Neurally Adjusted Ventilatory Assist (NAVA) is a cool way of signalling a ventilator to give a breath in sync with a patient's natural breathing pattern. It involves placing a sensor down the patient's esophagus and detecting the nervous signals to the diaphragm that would normally trigger a breath. That way you know when an attempted breath is happening sooner than the traditional way of watching for pressure/flow changes through the vent tubing.

TILIF #13: ♬ ♫ ♪ I've got you under my skin ♪ ♫ ♬

Last Monday, I had my first successful solo arterial line placement! Woot!

One of the defining parts of the job description of an intensivist is being comfortable doing minor sterile procedures at the bedside. So, while we are not surgeons, we need to be able to place arterial and central venous lines and do the associated cutting and sewing. Just like with normal surgeries, our patients are usually asleep and family is usually not around, which means, just like with normal surgeries, there is often music playing!

I know this is not what is portrayed on most medical dramas, but most ORs are playing the spotify playlist of the most senior surgeon in the room. I've listened to classic rock, rap, pop, folk, classical, country. And you never know what the whims of any particular surgeon will be on any particular day.

It's a strange sort of status symbol to be the one in the room with a half-dozen people to get  to pick the music. You'll notice if an attending scrubs out of a case and lets the resident finish closing the wound (a tedious and not particularly technically difficult task), that the resident may get to pick the music for the remainder of the time.

Well, our procedures may not be as big of a deal, but we still can play music and this was the first time I had (a) put in a line by myself, and, more importantly, (b) been the one to pick the music. Once all of our sterile gear was opened and the patient was comfortably sedated, the nurse for the room pulled up YouTube on the patient's entertainment screen and asked, "What'll it be, doc?"

I was a bit nervous about the procedure and initially tried to defer to whatever anyone else wanted, but she ignored call-outs from the resident and the other supervising fellow in the room and made clear eye-contact with me indicating that this was as necessary as the safety "time-out" we had just completed. Well, I had been on a big band kick recently and decided that I might as well dive on in. "Frank Sinatra, please!" 

She was initially taken aback but then I got an approving nod. "Haven't heard that one before. I like it!" And just like that we had a Sinatra playlist setting the mood for my (very slow and very cautious) placing of this kid's arterial line. It was actually really nice. I know Frank like the back of my hand, so it was like having a familiar beat to perform to. My favorite part though, was when, after I had already successfully placed the line, and was suturing in place, the song I've Got You Under My Skin came on. "A little on the nose," I said to groans.

TILIF: Pulmonary vascular resistance (PVR) has really weird units. PVR is the resistance that blood must overcome to pass through the pulmonary vasculature. It is defined analogously to Ohm's law for electrical resistance (resistance = voltage/current), except voltage is the pressure gradient through the lungs and the current is the cardiac output. Pressure can be measured in mmHg and the cardiac output is L/min. So, while you could keep the units as a simple mmHg⋅min/L, by swapping things out for slightly dated units of force, you get units of dynes⋅sec/cm⁵, which is, for some reason, the continued standard. At some point people were annoyed with this convoluted and completely unintuitive mess and named an entirely new unit after one of the pioneers in PVR research, Paul Woods. So you will sometimes see PVR listed in WUs, or Wood's Units.

Apparently John Deere is a big deal in Iowa. John Deere, the person, founded his company in the appropriately named middle-of-nowhere town of Grand Detour, IL before moving operations to the Mississippi River in the IL/IA state-line-spanning Quad Cities area. Also, apparently there are several very regionally dominant farming companies that have prominent color associations reminiscent of college sports with the Americana brand-loyalty of mid-century car companies.

To give a patient a granulocyte (a type of white blood cell) transfusion, you need 24-48 hours of lead time. This is because these cells don't keep and have to be very closely matched to the recipient. So you need to find the appropriate donor, give them a medication that causes granulocyte cell overproduction, wait at least a day for it to work, then transport them to your patient.

TILIF #12: Yeah-huh tagbacks!

"Tag-g-g! You're it!" This was not what I was expecting when beckoned into my patient's room. He had been coloring with crayons and waved me into the room as I walked past.

There's an adage in pediatrics that, compared to adults, kids get sick faster. They have a lot of physiologic reserve, so they are fine... they are fine... they are fine... until they are not. Accordingly, if a patient suddenly looks worse on the general pediatric floors, don't ignore it - they may need the ICU and soon. But the corollary is that children often quickly turn the corner toward recovery too.

As kids get sicker and get better they are moved in and out of the intensive care unit. The move to "the unit" is usually pretty quick. We always have a bed or two ready to emergently accept patients and can speedily adapt our nursing distribution to cover the other patients while we stabilize the new kid. Moving to the general floors, however, can be a bit of a waiting game. The stars need to align to have an appropriate room, bed/crib, nurse, and doctor ready at the same time to safely transfer care. And there's less urgency because the child's clinical condition is necessarily stable or improving for them to be leaving the ICU. Worst-case scenario, the child is getting a higher level of care than they need while they wait to transfer.

As I reach to tag my patient back, he squirms away in his hospital bed and stutters, "No tag-g-backs!" I'm a little shocked that he had thought this through so well.

While we grumble about how long it takes to transfer kids out of the unit, sometimes it's nice to have a relatively healthy kid around for a while. After all, everyone in the PICU has trained in general pediatrics first, so we've played games to get our physical exam more painlessly, chatted about Paw Patrol and Frozen ad nauseum, gotten countless high-fives, and waved "bye-bye" leaving each room^*. When most of your patients are either heavily sedated or just too sick to have normal kid interactions, you have to take every opportunity to remind yourself what you're working so hard to restore to your patients: the simple joys of being a kid. 

I snap my fingers and facetiously say, "Drat!" I scan the otherwise empty room for someone else to tag.

"G-go g-get the n-nurse!" he says excitedly.

That morning, the unit had an honor walk. This is the solemn event when all the available staff in the unit line the hallways to bear witness to an organ donor being escorted by their family to the operating room. It is such a hard decision that no parent expects to have to make. To be an eligible donor, the organs must be in pretty good condition, so these are usually children that were healthy and vibrant a few days ago until some tragic circumstance changed everything.

In this horrible moment, we - and by "we" I mean very experienced social workers - ask these parents to consent to sending the body of their recently deceased child, still in the hospital bed on "life-support," to undergo one last surgery to scavenge the usable tissues and ship them out to other nameless patients in desperate need. We try to remain as neutral as possible while presenting the choice, so as not to bias them towards doing something they don't believe in or will regret. But everyone involved is hoping beyond hope that they will say yes. It is so tempting to walk these parents to the opposite hallway in the unit were a patient and their family has been waiting for months for a new organ - their only chance for continued survival.

As I run out of the room and towards the nurses' station, the patient's nurse looks up with mild concern. "What's going on? Do you need something?" she asks.

"I just needed to tell you that..." [I poke her shoulder] "you're it! No tag-backs!"

An honor walk is an emotionally taxing event to participate in. The ICU can usually pause for a moment, but it doesn't stop. Other patients need our help and they can't wait for us to collect ourselves before returning to the job at hand. The ICU is always in motion. There are always new kids coming in and improved ones going out. There are always unstable patients that you need to pass-off to the night team, who will pass them right back to you in the morning, having taken the next steps toward whichever outcome.

But even knowing the emotional toll that participating will take, when you have taken care of a patient that eventually has an honor walk, you kind of want to be there when it happens. You may have been with that family as they arrived, as they were told that their baby wasn't coming back from this, and sometimes (as was the case for me today) you may have been part of the team that did the brain death exam. When those patients head to the OR for the final time, you kinda hope to be stuck holding the hot-potato; you gladly allow yourself to be "it" in the game of Tag.

"What?!" the nurse yells, so that our patient can hear, giggling in his bed. She storms towards the room on faux-outrage, "You got the doctor to tag me?! Well, you're it again! No tag-backs!"

TILIF: The pores of Khon are connections between alveoli (tiny air sacs) in the lungs and appear around the second year of life. A similar structure called the canals of Lambert connect bronchioles (the smallest air tubes of the respiratory tree) to adjacent alveoli. The canals develop around age 6. These two structures allow for the passage of fluid and bacteria, possibly contributing to increased risk of pneumonia, but they also allow for connections between adjacent parts of lungs, which decreases the risk of lung collapse or atelectasis, which is seen more commonly in children than adults.

*Teenagers particularly enjoy when you wave bye-bye