WILTIMS #358: Healthy advice and unhealthy nubs

One of the attendings pointed out the other day that the well baby nursery is the only place in the entire hospital where your patients are healthy. While normally the chief complaint of one of my patients is "stomach pain" or "shortness of breath," this week the chief complaint of all of my patients is "new baby." To be fair, that's one hell of a complaint; you try being ripped from your dark, warm, quiet home and being told to breath and eat and poop on your own for the first time. But existential complaints aside, all of these babies are healthy. If they weren't they would have been transferred to the neonatal ICU.

One awkward part of our job in the nursery is to provide what's known as "anticipatory guidance," which essentially means advice as to what to do and what to expect between now and the next time you see your primary pediatrician. This is super helpful and much appreciated for a first time mother. But when you have a mother of 4-now-5 as a patient, they know (or, at least, think they know) everything about babies.

The hardest part is if the mother's old habits are outdated or just plain wrong. It takes some skilled diplomacy to get them to even hear you out, much less actually follow through with your recommendations once they leave your care. Say advice without conviction and they'll tune you out; but get too preachy and they'll ignore you out of spite. Add into the mix that most of the medical students and residents don't have kids of their own yet (you know, with all that time we have) and it's amazing if anyone listens to us.

Switching gears, remember those cheap molded plastic toys like green army men or monkeys in a barrel? You know how there was always a little nub of plastic that shows you where they injected the mold? Well babies have those too. The most obvious one is, of course, the umbilical cord - the literal connection to the mom. But there are a couple other vestiges of the manufacturing process that we are very keen to check in the hours and days after birth. One such remnant is the end of the neural tube, which is like the primitive tube (for once biologists actually named something intuitively) that the spinal cord develops in.

For a good chunk of early human development, this tube is open to the fluid around the fetus. Sometimes this tube stays open on one or both sides. If the top end remains open, it's called anencephaly; if the bottom does, it is a meningocele or myelomeningocele - collectively known as spina bifida.

TIL: Diastematomyelia is when the tail end of the spinal cord is split down the middle by bone or cartilage. The symptoms often include foot or leg numbness or weakness progressing to bowel and urinary dysfunction.

WILTIMS #195: Mama bears

TIL: If a UTI spreads up from the bladder into the ureters and kidneys, normal UTI antibiotics will no longer effectively treat the infection. This is because they often clear from the bloodstream very quickly and concentrate in the bladder (this is why we use them for UTIs). But since they clear so well through the kidneys, they never reach a high enough concentration to kill the bacteria there before moving straight down the urinary tract.

Aicardi syndrome is a genetic condition caused by a malformation of the brain. Specifically, the corpus callosum which connects the two hemispheres of the brain, is absent. Children born with this syndrome often have severe seizures and very specific retinal tears called lacunae. The incidence if about 1 in every 150,000 live births and the prognosis for development and lifespan is generally very poor.

Things I already knew: Parents of developmentally disabled children are fiercely intimidating people. We had a panel of mothers of kids with chronic health conditions come speak to our entire class which had donned its white coats and ties (and dresses, etc.) - that's an intimidating audience! But these women had learned to manage whole teams of doctors and navigate the most confusing parts of the health system, so 200 medical students were nothing to worry over.

First Last Summer Post

So begins my last summer. No, I'm not moving north of the Wall or foretelling my untimely demise. This is the last summer break I will get as a student. And like many med students, I'm voluntarily spending it productively and merely dreaming of the exotic destinations to which my wiser classmates have ventured. Earlier this week I, rather abruptly, started my summer clinical research "program" in the Pediatric Intensive Care Unit (PICU) at the local children's hospital. I hesitate to use the term program because that implies that there is some sort of plan, schedule or central organizing force. Like any great adventure, mine seems decidedly unscripted.

On Wednesday, I met with my primary advisor and was promptly told to create a ten minute presentation for the next morning to present to the twenty or so second year residents (doctors four years my senior)... and this presentation would be at the house of the pediatric residency director for the hospital... on a research project about which I only had cursory knowledge. Given the situation and the resultant lack of sleep, it went pretty well. Of course the audience wasn't exactly the most receptive I've ever had, as the project essentially creates slightly more work for some of the most overworked people in medicine. Rough crowd.

Thankfully, this summer experience is not all research based. At that first meeting with my project's PI, or principal investigator, I was also told that the entire PICU was open to me. I can attend morning rounds, departmental lectures, and unit meetings. I can shadow the residents and generally lurk about the unit as much as I want. I took my first opportunity at this this morning and joined the residents and their attending physician on morning rounds.

For the uninitiated, morning rounds are a daily exercise at teaching hospitals wherein the team of doctors physically tours the unit one bed at a time, discussing updates on the condition and current treatment plan for each patient. If you've ever been a patient or family member visiting during these early morning hours, you know it can be quite the imposing experience. In an ICU such as ours, the rooms are all private and open to the unit with huge glass double doors. The doctors stand in a semicircle around the door and talk to each other in a foreign language of acronyms, numbers, and medical terminology. The resident in charge of the patient gives a report to the attending with the help of the patient's current nurse. The attending gives his or her advice and pounces on every teaching opportunity to reinforce (or refute) with real life experience all the knowledge the young doctors have learned from books and classes.

The patient and their family are briefly greeted but this visit is not for them. This is the only time each day that all of the doctors are in the same place at once and there's no time to translate. As I am not nearly fluent myself, I spent most of my time this morning taking in the scene and watching the interactions of the players. The most interesting people were the parents. The ones with kids with chronic conditions smiled when we came by and politely listened. You could see them nod with recognition when they heard the key words that were important yesterday or a year ago during their last admission. The doctors also know that experienced parents can be valuable experts in their children's conditions and will ask their opinions.

The hardest part was watching the novice parents, having been thrust into this sterile world by a tragic accident or life-altering diagnosis. To them the words are useless; each could mean their child's salvation or condemnation, but they can't tell which. Instead they are doing the same as me and watching faces. Every sign of frustration or resignation from the doctors causes them physical pain. In teary desperation they seem to silently plead for someone to tell them it will be alright, if only so that they can more honestly whisper the same to their unconscious child.

People often ask how doctors and nurses can stand working in this world of innocent lives torn apart, possibly to never be put back together again. The best response I've heard is that it is these the patients who are most worth fighting for. I'd rather spend my energy on an innocent child with a full life of potential than, for instance, an elderly patient suffering from a self imposed ailment, even if the outcome is potentially more tragic with the child.

I'm looking forward to exploring more about the PICU and clinical research this summer and periodically sharing my existential musings with you. Thanks for reading!