Another "weekend", another call day. Thankfully, Sunday was already my third of four on-call shifts, so I'm pumping them out early. It sure would be nice to have a couple days off in a row though.
Friday was our first game of the flag football season at my school. Whereas the first and second year students each field a handful of teams, with all our our classmates dispersed to hospitals throughout the tri-state area, my whole class of 200+ students only is fielding one team. This week we only managed 6 players, but by the "luck" of the draw, were playing the scrappiest of first-year teams and won handedly.
Remembering back, playing flag football with some second- and third-year students in front of the ER during my first weeks on campus was really the first time I felt like I had really made it to med school. Now I'm the third year, strolling lazily out of the hospital with my stethoscope and crumpled patient list. It's a nice reminder that I'm over half-way done.
FridayIL: Finding the cause of a first-time seizure is actually worst prognostically than not finding one. Statistically, if we find the cause, you are more likely to have more seizures in the future, but if we work you up and can't find an answer, then odds are, you won't have another.
SundayIL: Rhinitis medicamentosa is nasal congestion brought on by extended use of topical decongestants. Essentially, your body adapts to the decongestant and causes the baseline state to be a mildly congested one. Yet another medical condition caused by treating a medical condition. Only use medications as instructed!
Sunday, August 30, 2015
Thursday, August 27, 2015
WILTIMS #343-344: Coffea arabica 12oz PO QAM prn fatigue
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| Pain indeed |
Amidst the series of disasters yesterday, there was a pretty interesting lecture on radiologic findings in pediatrics. The dark room very nearly put me asleep, but the topic was interesting enough to keep me semi-conscious. An hour and one game of "find the fecalith" later, we stumbled out of the conference room. Then a surprisingly big moment occurred: I went and got coffee with my classmates.
I have never been a coffee drinker, and by that I don't mean that I like tea more than coffee but rather that, excluding one cup accidentally served to me with dessert at a family dinner, I have never had a cup of coffee. My joke has always been that I'm saving it for med school; I guess the time has come. I was exhausted, it was morning, soda/tea just wouldn't cut it: I needed some coffee.
And then, of course, I immediately did two things: I burned my tongue and I spilled on my patient list.WednesdayIL: A normally inflated lung goes down to the 9th or 10th rib... unless the patient has abdominal distension. Then it becomes a physics problem. If the abdomen is pushing up against the diaphragm just as hard as the overinflated lung is pushing from above, then the lungs will appear to be normally inflated, even though they are at a much higher than normal pressure.
Cardiomyopathy (heart muscle disease) in patients using TPN (total parenteral (injectable) nutrition) is likely caused by a deficiency in the element selenium.
Look carefully at an x-ray of a swallowed "coin" in a child. A dime is fine to go through the digestive tract; a watch battery is not.
TIL: Scoliosis causes respiratory difficulties not because the bend of the spine constricts the lungs, but because the curve offsets the left and right sides of the chest, restricting the normal "bucket-handle" motion of expansion of the chest cavity.
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| Normal bucket-handle expansion |
Tuesday, August 25, 2015
WILTIMS #341-342: Inpatient beginnings
This week is the first of three on the inpatient floors of our pediatric hospital. This is a very different environment from the ER. Significantly more structured and less chaotic. This is what a typical day is like:
At the moment, I'm on the subspecialty team as opposed to the general pediatrics team. This means that we get interesting patients, but our day is a little more chaotic because instead of having one general pediatric attending physician to travel around with during rounds, we have half a dozen depending on which specialties are responsible for our patients. The big ones seem to be pulmonology, neurology, GI and adolescent med. So each day we need to coordinate with all of these specialists to see when they will be ready to lead our herd of doctor-y people around the hospital.
Day one was pretty nerve wracking but, by day two, I feel like I've got a handle on what is expected of me. Pretty fun, if a bit tiring.
MondayIL: Chronic right middle lobe atelectasis (aka right middle lobe syndrome) is the damage or partial collapse of only the middle lobe of the right lung. This lobe is particularly prone to collapse because of its relatively narrow branch point and because it is surrounded by lymph nodes. Mucous, inflammation, cancer, or lymphadenopathy can all restrict that narrow opening. Or, even without touching the opening, the encompassing lymph nodes can all become inflamed and collapse the lung on their own.
TIL: Always have a replacement tracheotomy tube (a tube that passes through a hole in the throat allowing air into the lungs, usually to bypass some blockage of the airway in the mouth or upper throat) at the bedside in case of emergencies.
Also, a common problem with asthmatic young children is getting them to sit still long enough to get a nebulizer treatment. Sometimes they get upset and start crying and parents/nurses/doctors will say, "At least we know that they're getting the medication every time the breathe in while crying!" This is not true. The breathing you do while violently crying is very different from the kind you do while calm. The turbulent airflow causes most of the aerosolized medication to get stuck on the patient's tongue or throat rather than getting into the lungs where they actually work.
06:45-07:00 - Arrive early to check on your patients.
07:00-08:00 - Morning "sign-out": Listen in as the night residents give their patients to the day residents and then continue checking on your patients.
08:00-08:45 - Morning conference: Gather with the all the residents in pediatrics to go over some practice board-style questions and then work through the stories of 1-2 current interesting patients as a group to see where we've gone right and wrong with their treatment thus far.
08:45-09:15 - Try to finish up any research you need to do on your patients before rounds begin.
09:15-12:00 - Morning rounds: The entire team (usually one attending, one senior resident, one second year resident, two interns, one sub-intern, three medical students) goes from room to room around the hospital to see each of our patients. The treating nurse, parent and patient are all invited to participate. The least senior team member following the patient presents the case to the attending. Depending on the attending, this can be a pleasant learning experience of a humiliating pimp-session. This is, by far, the most nerve-wracking thing we do on a day-to-day basis.
12:00-13:00 - Noon conference: We each lunch with all the pediatric residents and med students while listening to a lecture on some topic.
13:00-16:00 - Write progress and/or discharge notes on our patients. We can't sign the notes (electronically) until the resident supervising us reads through the note and writes an addendum documenting their approval.
16:00-17:00 (or later!) - Wait around until you've finished your notes and been given permission to leave.
At the moment, I'm on the subspecialty team as opposed to the general pediatrics team. This means that we get interesting patients, but our day is a little more chaotic because instead of having one general pediatric attending physician to travel around with during rounds, we have half a dozen depending on which specialties are responsible for our patients. The big ones seem to be pulmonology, neurology, GI and adolescent med. So each day we need to coordinate with all of these specialists to see when they will be ready to lead our herd of doctor-y people around the hospital.
Day one was pretty nerve wracking but, by day two, I feel like I've got a handle on what is expected of me. Pretty fun, if a bit tiring.
MondayIL: Chronic right middle lobe atelectasis (aka right middle lobe syndrome) is the damage or partial collapse of only the middle lobe of the right lung. This lobe is particularly prone to collapse because of its relatively narrow branch point and because it is surrounded by lymph nodes. Mucous, inflammation, cancer, or lymphadenopathy can all restrict that narrow opening. Or, even without touching the opening, the encompassing lymph nodes can all become inflamed and collapse the lung on their own.
TIL: Always have a replacement tracheotomy tube (a tube that passes through a hole in the throat allowing air into the lungs, usually to bypass some blockage of the airway in the mouth or upper throat) at the bedside in case of emergencies.
Also, a common problem with asthmatic young children is getting them to sit still long enough to get a nebulizer treatment. Sometimes they get upset and start crying and parents/nurses/doctors will say, "At least we know that they're getting the medication every time the breathe in while crying!" This is not true. The breathing you do while violently crying is very different from the kind you do while calm. The turbulent airflow causes most of the aerosolized medication to get stuck on the patient's tongue or throat rather than getting into the lungs where they actually work.
Sunday, August 23, 2015
WILTIMS #340: "On-call"
Yesterday was my first of four on-call shifts for this clerkship. It seems that these shifts are only called "on-call" to make us feel like like we are important enough to call about anything. Really, they're just extra shifts at odd hours to get us used to long miserable hours. This one was 10 hours in the ER. I've worked 10, 12, and more hours before but when you're as useless as we are, the time sure flies like a brick.
I had one other classmate who was on-call yesterday, only this was his first day in the ER and this was my last. We had a good laugh as he made the same mistakes I did last Tuesday by treating the ER like an inpatient ward. When a patient is admitted for an inpatient stay, we need to know everything about them. We need to ask about this illness, all other illnesses, their family's illnesses, their living conditions, school, social life, habits, etc, etc. But in the ER, all we really need to know is how long the fever/rash/vomiting has been going on and what body part needs to be x-rayed.
Our most anxiety inducing task in the ER is presenting the patient's case to the attending physician (the head honcho who oversees all care in the department). In the ER, the attending really only has the time and need for a very bare bones assessment and plan. So when my colleague jumped into the most thorough presentation I have ever heard, we all listened wide-eyed and I was reminded of this:
YesterdayIL: If a patient asks you if you've done a simple procedure before, the answer is yes. It might more accurately be, "Yes I've done something not entirely dissimilar to that procedure once, two years ago and it only went so-so," but for the sake of your education and the patient's mental well-being, just say "yes."
It seems dishonest, but especially if you're inexperienced, you will be guided through every step by an extremely qualified overseeing physician. The whole point of teaching medical students for years before putting them in clinical situations is so that we know exactly what the instructing physician means as s/he guides us through each step. We know all the whats (body parts, medications, tools) and most of the whys, we just haven't had an opportunity to master the hows. With proper instruction we are essentially a new pair of hands acting out an old physicians wishes.
Of course, if a patient asks point blank how many times we have done this exact procedure, none of us are going to lie. Hopefully if the routine nature of the procedure is adequately explained, the patient (or parent) would be willing to let us continue even knowing our inexperience. But when possible, it can be useful to use confidence to garner some mutually beneficial trust, even at the expense of full-disclosure.
I had one other classmate who was on-call yesterday, only this was his first day in the ER and this was my last. We had a good laugh as he made the same mistakes I did last Tuesday by treating the ER like an inpatient ward. When a patient is admitted for an inpatient stay, we need to know everything about them. We need to ask about this illness, all other illnesses, their family's illnesses, their living conditions, school, social life, habits, etc, etc. But in the ER, all we really need to know is how long the fever/rash/vomiting has been going on and what body part needs to be x-rayed.
Our most anxiety inducing task in the ER is presenting the patient's case to the attending physician (the head honcho who oversees all care in the department). In the ER, the attending really only has the time and need for a very bare bones assessment and plan. So when my colleague jumped into the most thorough presentation I have ever heard, we all listened wide-eyed and I was reminded of this:
YesterdayIL: If a patient asks you if you've done a simple procedure before, the answer is yes. It might more accurately be, "Yes I've done something not entirely dissimilar to that procedure once, two years ago and it only went so-so," but for the sake of your education and the patient's mental well-being, just say "yes."
It seems dishonest, but especially if you're inexperienced, you will be guided through every step by an extremely qualified overseeing physician. The whole point of teaching medical students for years before putting them in clinical situations is so that we know exactly what the instructing physician means as s/he guides us through each step. We know all the whats (body parts, medications, tools) and most of the whys, we just haven't had an opportunity to master the hows. With proper instruction we are essentially a new pair of hands acting out an old physicians wishes.
Of course, if a patient asks point blank how many times we have done this exact procedure, none of us are going to lie. Hopefully if the routine nature of the procedure is adequately explained, the patient (or parent) would be willing to let us continue even knowing our inexperience. But when possible, it can be useful to use confidence to garner some mutually beneficial trust, even at the expense of full-disclosure.
Saturday, August 22, 2015
WILTIMS #338-339: Sorry for the wait
My weird ER schedule has been throwing me off of my blog-writing groove. Thankfully, my week in the ER is already over, but this does not bode well for my blog during the surgery clerkship!
Thursday was crazy-busy in the ER. At one point we had 35 kids in the system even though we only have 19 beds (not rooms, mind you, but beds - half of which are just gurneys lining the halls). This makes for a lot of running around, though not many teaching moments. For a while, I was following a resident who was just seeing kids in the waiting room. These patients never even got a bed in the ER and were seen, treated, and discharged straight from the waiting room. Honestly, this was a pretty sweet deal for them because they probably saved a several hour wait and avoided the cramped chaos of the ER hallways.
Nights like this are when the ER triage system really annoys some parents. Triage is, of course, the assessment and care for patients by order of severity. That means that if you come in with a paper cut but 15 traumas come in after you, you'll be seen 16th.
One particular family came in with an infant who probably had a super-mild, super-common viral infection, but because of the slew of sicker kids that came in at the same time, they were stuck on a gurney for nearly five hours. I interviewed them when they arrived and became the unlucky go-between for them and their care team. It's hard knowing what they need and not being able to get them it. But I did have their gratitude to grabbing them a couple extra formula samples for the child and exchanging some crumpled one-dollar bills for crisper ones that might work in the vending machines. As always, little things can go along way toward showing that your empathy is not just words.
ThursdayIL: "Witches milk" is a colloquial term for male infant lactation caused by hormones in breast milk.
FridayIL: Anemia is very common in small children due to the fluctuations of iron that they get from breast milk and formula. Do not freak out parents by mentioning this when it comes back in a lab test.
Thursday, August 20, 2015
WILTIMS #337: Nose goes!
Today (I didn't get off until 10, so I'm writing this "tomorrow", but whatever - my blog, my rules) was much better. Chaotic, but fun.
The most work-intensive thing I did was to help hold down a crying baby as he was stuck with a needle six times in an eventually successful attempt to put in an IV. It's actually pretty funny how easily pacified he was by, well... a pacifier. Screaming bloody murder until some sugar-water on a pacifier is put in his mouth, then it didn't matter that we were fishing around his pudgy arm with a needle for another half-hour. I never thought I could be so happy to see blood coming out of a baby. #contextiseverything
The most fun I had today was talking to the little cousin of a patient, who kept sneaking out of their room to creep on the other sick kids while wearing this huge jacket his uncle gave him. He could barely walk with the jacket coming down past his knees, but he still somehow managed to peek on tip-toes at the sick girl next-door.
TIL: ...how to do oral and nasal swabs for sputum culture lab tests. Uh... Stick the stick in the patient's mouth or nose. Tada! Not as easy when they're crying and biting down, but simple enough in theory.
Wednesday, August 19, 2015
WILTIMS #336: Oof
Today was my first day in the Pediatric ER, and I could use a hug (please don't actually hug me; I have someone for that and she's very good at it).
There were some tough cases today - cases that I'm not ready to share with the internet yet. Some of you may know that I used to work in an ICU back in California. Part of my job involved rotating through as a clerk in the pediatric ICU, and that's where you see some of the most heartwarming and heartbreaking stories in medicine. At the time, I feel like I had built up a sort of immunity to the emotional toll; I still felt for our patients (and there were still tears at the end of the day), but the impact was blunted. I wasn't quite ready to deal with that right out of the gate today, on day two of my Peds clerkship.
All of that aside, it is fun to be back in a medical hospital. I really enjoyed psych, but physical medicine (pediatric or not) really seems more my cup of tea.
TIL: A Wood's lamp, named for physicist Robert Wood, is the medical term for an ultraviolet (aka black) light. A common portable version is essentially two small black lights surrounding a magnifying glass used to look for corneal abrasions (eye scratches) as visualized by a fluorescent dye. The dye is a very subtle yellow under normal light, but under UV it glows very bright. If there is a scratch on the surface of the eye, you'd never be able to see it normally. But the dye is like glitter; it gets everywhere. Once you turn the Wood's lamp on, the scratch will show as a neon-yellow line on the surface of the eye.
There were some tough cases today - cases that I'm not ready to share with the internet yet. Some of you may know that I used to work in an ICU back in California. Part of my job involved rotating through as a clerk in the pediatric ICU, and that's where you see some of the most heartwarming and heartbreaking stories in medicine. At the time, I feel like I had built up a sort of immunity to the emotional toll; I still felt for our patients (and there were still tears at the end of the day), but the impact was blunted. I wasn't quite ready to deal with that right out of the gate today, on day two of my Peds clerkship.
All of that aside, it is fun to be back in a medical hospital. I really enjoyed psych, but physical medicine (pediatric or not) really seems more my cup of tea.
TIL: A Wood's lamp, named for physicist Robert Wood, is the medical term for an ultraviolet (aka black) light. A common portable version is essentially two small black lights surrounding a magnifying glass used to look for corneal abrasions (eye scratches) as visualized by a fluorescent dye. The dye is a very subtle yellow under normal light, but under UV it glows very bright. If there is a scratch on the surface of the eye, you'd never be able to see it normally. But the dye is like glitter; it gets everywhere. Once you turn the Wood's lamp on, the scratch will show as a neon-yellow line on the surface of the eye.
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