TILIF #3: As easy as *snap*

Today I learned a new technique to open a patient's mouth one handed as you prepare to maneuver the laryngoscope blade in the patient's pharynx. Then use your dominant hand (which you are keeping free for placing the tube in a moment) and place your thumb against your middle finger, as though you are going to snap your fingers. You then let your fingers slid past each other onto the patient's lips, such that your thumb is now pressing down on the lower lip and your middle finger is pressing up on the upper lip. With a sort of scissoring action, you can now open the moth one handed to allow access to your off hand which is holding the laryngoscope blade (basically a fancy tongue depressor with a built in flashlight and handle).

This was all part of our first weekly PICU fellow lecture series. I love that my lectures have become so focused onto things that I actually find interesting and useful - a far cry from required topics like histology in med school, or newborn care in residency.

TILIF #2: Planes, train(ing)s, and how a heart heals

I think today marks the end of my official orientation activities for this job. Maybe? We needed to be oriented to the University, to the Department of Pediatrics, and to the Division of Pediatric Critical Care - each with their own priorities and complicated logistics to communicate. There was an amusing progression from less to more relevant information and tours of smaller and smaller areas.

For example:

"Over there is the children's hospital!"

to

"This floor is the PICU!"

to

"This corner of this storeroom is where the ultrasound machines are kept!"

Of course the end of orientation implies that I now know the minimum information to do this job, which is surprising. I guess the important thing is I know where to find any information I'm missing going forward.

TILIF: Always place a chest tube for any size pneumothorax before transporting the patient by air. A pneumothorax (pneumo- = air, -thorax = chest) is when you have air in your chest but outside your lungs. This can be caused by external trauma (e.g. knife to the chest) or internal trauma (e.g. popping a lung from having too high of ventilator settings). The problem with this is the air has no where to go and will continue to fill up the chest, taking up the space that the lungs and heart need in order to work. A small pneumothorax is no big deal and will be reabsorbed by the body in time; a large one will tamponade the heart, preventing it from filling with blood and killing the patient.

If you are transporting a patient by air, the lower pressure experienced even in a pressurized cabin* will allow any air of a pneumothorax to expand to a larger volume, which, per the principles above, could be deadly. Accordingly, before putting someone with a pneumothorax on a plane, have the referring hospital put in a chest tube, so that any increasing volume of air can be safely vented thanks to a one-way valve on the tube. Pro-tip: flush the chest tube with some water to minimize any additional air in the tubing that might expand at altitude.

I also learned, there are two broad types of heart transplant: orthotopic and heterotopic, aka "piggyback." Orthotopic is basically what you think of as a transplant, when you put the patient on bypass, take out the old heart, put in the new heart, and take the patient off bypass. Heterotopic heart transplants are much less common and consist of leaving the old heart in the patient and installing the new one, essentially in parallel. A reason you might attempt this is if the native heart just needs time to recover from some insult but has the potential to return to full strength in the future. Additionally, a benefit of keeping the old heart in place is that you can fall back on it if the new one goes into acute transplant rejection. However, this type of transplant is much more complex and not seen as worth the risk now that we have better anti-rejection medications.

*Bonus fact: Airplanes at cruising altitude are pressurized to the equivalent of 8000 feet, not sea level. So, one of the first things that is requested by health care professionals if there is a medical emergency on a plane is for the pilot to fly the plane to the lowest safe altitude. This is effectively like putting an oxygen mask on the patient, just because the partial pressure of oxygen is so much higher near the ground than at cruising altitude.

The Phoenix Rises Again: Fellowship Begins (TILIF #1)

Yesterday was my first shift as a pediatric critical care fellow. The last time I posted was in the midst of my pediatric residency, a three-year program meant to prepare me to either become a primary care general pediatrician or discover what type of subspecialist training I want to pursue.

I had a pretty clear understanding within a month of starting residency that I did not want to be a general pediatrician. It took longer to confirm which subspecialty I was interested in, because the one I was eying was not available to me until my second year of residency. After a couple rotations through the PICU, I was sold. This place had the most: the most interesting stories, the most extreme emotions, the most impact on families, the place where I was the most happy, and where I had the most to learn.

It's the last point that is most relevant for today. On the first day of residency, a pediatric resident is far less capable than a 4th or even 3rd year medical student because they have only done a couple rotations in their field and they are at least 6 months further removed from that experience than they were as medical students. Same goes for fellowship; I have only worked 3 months in the PICU in 3 years of residency, but now I'm a fellow who is supposed to lead a team of residents (under the supervision of an attending physician). As they say, if you already knew everything, then you wouldn't need med school/residency/fellowship/etc. It's still jarring - like starting high school: you may have been king of the campus in 8th grade, but now you're a lowly freshman.

There's a lot of critical care medicine that I do not know yet but some things that I do. I am effectively going to spend 18 of the next 36 months in the ICU and the rest doing research to add to the field, so I will have every opportunity to learn. Thankfully, some of my prior training does carry over. I know how to talk through complicated medicine with scared families. I know how to clear up and prevent miscommunication. I know how to be present for families when they need it. And I know how to throw myself at scary new situations with blind faith in the belief that I can figure it out as I go and survive to do better another day. These are the truly important things you learn in residency.

I was able to put several of these skills to work on my first shift, which helped me dampen the ever-present impostor syndrome and feel a little less useless. The hardest thing I did today is difficult to study for: I bore witness to the ritual of a brain death exam of a previously vibrant toddler.

This procedure is not really for answering a question, but rather affording an abundance of caution to the act of making official what we already firmly believe - that despite our most extreme interventions, our patient has died. It involves thoroughly testing all of the brain's most basic or primitive functions to see if any residual activity remains despite all outward appearances to the contrary. Before you can start you must have stopped any medications and fixed any abnormality that could cause the false appearance of death - such as sedatives or hypothermia. The exam culminates with an apnea test, where you turn off the ventilator that is breathing for the patient and watch for any response before checking a blood sample after 5 minutes to document that their blood hasn't been magically getting oxygen.

Watching a child not breathe for 5 minutes was rough, particularly for the parents (who can choose to be present or not). The hardest thing for me was seeing a stuffed animal fall to the floor in the shuffle of moving sheets. I had only known this patient for a few hours and only as a unconscious and unresponsive kid on a ventilator - which describes several children on the unit. But the ragged, discolored, stuffed dog ironically brought to life this child that we were in the process of declaring dead. The dog had been hugged, drooled on, dragged around, and generally loved by this child who would never play again. The stuffed dog won't someday be embarrassingly brought to a sleepover or college - not passed down to future kids. Only in that moment did I glimpse a sliver of the pain that the parents crying on the other side of the bed were going through. Managed not to cry until I got home. Little victories.

As melancholy as this experience sounds, it is such an honor to be a part of a family's story during these few days that will stay with them for the rest of their lives. If I can help them make the memories of this horrible time a little better, even if there was nothing we could do to change the physical outcome, then I'm more than willing to shed a few tears myself. I hope these situations never become mundane - these feelings never banal; they fuel my love of life, my respect for death, and my drive to make the most of the time I have. May the next three years help me continue to grow and learn from the extraordinary experiences in which I have the privilege of taking part.

TILIF: The Taussig-Bing anomaly is a version of double outlet right ventricle (DORV) congenital cardiac malformation where there is also a subpulmonary ventricular septal defect (VSD).

Tweezers are not as easy to come by here compared to my old hospital.

Time is relative. The 5 minutes before cardiac ICU rounds just flies by; the 5 minutes of a brain death apnea test last an eternity.

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.