Feelings of Inadequacy

Ok, so I don't know a lot about pediatrics.  I get that now.  All of my attendings are right - they are not just "little adults."

So I had my first shift in the pediatric ED at WCHOB (Women & Children's Hospital of Buffalo.)  It didn't start off well given that I was 20 minutes late due to a car accident on the highway, and somewhat poor planning on my part.  There's a big difference between 5:30 in the morning traffic and 07:30 in the morning traffic headed downtown.  Not a good first impression.

Given that the system in terms of signing up for patients is similar to that at the other hospitals, I jumped right in.  I signed up for my first patient, "mouth sores."  I thought, no problem.  Probably something very benign.  Of course, as soon as I started getting the history (patient had ITP and they weren't mouth sore but actually petechiae), I realized it wasn't just a simple case.  However, I casually asked the parent when their last visit had been and what had been done, and I developed my plan from there:  get a CBC (complete blood count) and see what the platelets are doing.  I presented this to my attending, who agreed with the plan.  Whew... after putting in the order I had a few minutes to sit and read about ITP and see what my treatment options would be when the results came back.  I also was able to research the patient a little more and read about prior admissions and treatments.  First one down. 

My next patient was a little girl who'd had a febrile seizure.  Somewhat common and you don't really do much except find the source of the fever.  Of course, I wasn't sure what to do, and stumbled a bit during my presentation.  My attending redirected me, and I sat and read about febrile seizures while I waited for lab results.  She eventually got sent home with the diagnosis of bronchiolitis.

Next came a teeny 2 month old who wasn't breathing well.  We gave him a breathing treatment which really didn't improve matters.  We tested him for the common viral infections, which came back negative.  We made sure he could eat and drink ok, and had actually thought to send him home, but he could not keep up his oxygenation saturations (O2 sats) and needed to be admitted.  I will be following up on him.

My next patient had a rash.  Great big wheals all over her body with no idea what had caused them.  We went through all of the possible foods she'd had since the night before.  We went through the list of laundry detergents, soaps, perfumes, new clothing, old clothing, possible chemicals she might have been exposed to, even possible pets.  Nothing.  She gets benadryl and was advised to keep an eye out for possible inciting causes.  Will follow-up at some point and see if anything pops up.

The six-month-old I saw with "wheezing" was not wheezing by the time I saw her in the room.  She smiled broadly at me with great big cheeks and let me examine her with no problem.  I could smell the cigarette smoke on her parents' clothing as soon as I walked in the room.  Of course, they "never smoke in the house."  She was sent home with an inhaler and instructions on how to use it.

My last patient was a 16 year old with knee pain.  I put his knee through all of its paces and could find nothing wrong on my exam.  We did x-rays and found nothing obviously wrong.  I sent him home with ibuprofen and recommendations for rest and ice packs.  Sometimes you're just at a loss.

And, that's it for my first day.  We actually had a lull of about an hour and a half with no new patients coming in, and we had plenty of providers with a senior ED resident, a Med-peds resident, myself, a peds resident, a family practice resident and two physician's assistants.

The only other thing of note is that one of my new duties is taking "Expect Notes."  These are calls from doctor's offices or clinics when they are sending patients to the Emergency Department for further evaluation.  Some of the patients from the calls that I took but did not see:

2 year old that got into his parent's medications - charcoal lavage and observation

2 month old that "fell off the bed" - came in with a skull fracture and a subdural hematoma.  being admitted and Child Protective Services was contacted.  One, 2 month olds don't roll, and they don't get subdural hematomas.  Something is just a little hinky there.

16 year old whose robe caught on fire from a space heater and who was coming in with 2nd degree burns on their hands - he had just gotten there when I was leaving.

Several abdominal pains and upper respiratory infection patients as well.

The one interesting event was the invasion of the E.D. by a woman who was convinced that her 5 year old daughter had been brought into the E.D., and that we were hiding her there.  She was ok initially, but then started trying to go from room to room opening doors and needed to be led away by security.  One of the RN's recognized her as the mother of 2 children that had been sexually abused by their father.  They commented on some possible psych issues regarding the mother.    My understanding is that she was taken out of the hospital with a warning to not return.

Well, that's it for the first shift.  Tomorrow is Grand Rounds Wednesday, so meetings all morning.  Until then!

Tags: Idiopathic thrombocytopenia purpura, bronchiolitis, WCHOB, RSV, febrile seizure, child abuse, urticaria