Far Side Cartoon - Gary Larson
I really don't know what to write about. It seems pretty basic at the moment: I show up for pre-rounds about 0630, get all of my patients' information, start writing my notes, formal rounds are at 0800, they end around 1020, we have Medicine Morning Report at 1030, that lasts about an hour, we then come back to the unit to finish up notes and assignments for the day, you sign out your patients around 1600 unless you're on "short call" such as I was tonight in which case you take admissions until 2030, and then come back the next morning and start all over again.
My patients are interesting:
An 18 year old with Guillain Barre Syndrome that has completely taken over her nervous system and left her completely paralyzed. She's on a ventilator and getting treatments to try to "clean" her blood of the antibodies that are affecting her nerves (plasmapheresis.) Best case scenario is that she will start to recover in about a week (she's already been here a week) and come off the vent. Worst case is that she will need to have a tracheostomy placed and will take over a month to recover from the initial insult. We'll see. Right now she's battling a pneumonia. However, she's young and healthy and should do all right.
I have a 39 year old with bad insulin dependent diabetes who came in with Diabetic Ketoacidosis. Oh yeah, she's been in and out of the hospital for over 10 years with the same thing. So much so that most of the staff know her and her history; which includes experimenting with multiple drugs, not taking her medication, and generally not caring for her own health.
My last patient has lupus. She also doesn't like to take care of herself. Her diet consists of pizza and potato chips, sodas and snacks. She's got a heart condition where too much fluid makes her short of breath (not helped by her years of smoking) and too little fluid causes heart issues since she needs a higher volume to maintain her blood pressure. However, the fact that she's also "non-compliant" means she's a frequent flier as well. Also, I hate to say, but she's something of a slug: doesn't like toget out of bed and wants everything done for her.
We just started yesterday and not much happened so I didn't write. I had short call today, but I was protected by my "white cloud" and only got the 39 year old as an admission this morning and nothing else. I have Grand Round Wednesday tomorrow after I pre-round on my patients. Then I will "clean up" for a couple of hours afterward.
We'll have to see how things develop over the next couple of days. For now... the fun is just beginning.
The sea does not reward those who are too anxious, too greedy, or tooimpatient. To dig for treasures shows not only impatience and greed,but lack of faith. Patience, patience, patience, is what the seateaches. Patience and faith. One should lie empty, open, choiceless asa beach -- waiting for a gift from the sea.
- Anne Morrow Lindbergh
I am back from vacation (aka my honeymoon) and about to start my new rotation in the MICU (Medical Intensive Care Unit) tomorrow. I know that things will get a bit technical and, maybe, controversial as I go through the next month... but, before then, let's reflect on a great week:
I was on the Riviera Maya at a great resort (the Grand Mayan) which is located between Puerto Morelos and Playa del Carmen. From there we drove up to Cancun, down to Xel-Ha and Tulum, and then took the ferry to Cozumel for a day of awesome snorkeling (pics still being developed) and amazement at the sheer beauty of nature. Enjoy the mini slideshow. If you'd like to see a larger collection of the over 125 pics I took, you can go to my facebook.com page: facebook.com/album
Enjoy!!
Well, it's over... I just got home from my final shift of this rotation at WCHOB. It was a night of asthmatics for the most part. Neb treatment, steroids, another neb, pulse ox's still low, another neb, kid's heartrates and jitteriness levels rising. Etc.
Plus, to be honest, I had a bit of "clock-watching" going on, and I didn't really want to be there. All I kept thinking about was, "8 more hours and then I am on vacation." "Six more hours..." "Four more hours..." "Will this night ever end...?"
And, it did...! Woohoo...!!!!
I finished the last of my packing. Now I need to run downstairs and make sure everything is in order for the cats. One of my work colleagues will be cat-sitting. Or as she calls it, "Dog and Cat" sitting since she feels Winston is almost like a little dog instead of a cat considering the way he likes to jump up on people when they come over to the house.
I am posting my seal graphics as a slide show for your viewing pleasure.
If you've been following the seal photos and counts (last count: 124.899) over the last couple of weeks, the HSUS has stopped reporting from the ice. The EU will most likely be making an announcement to ban seal products some time in the next couple of months. Pressure from all sides and low prices have decreased the number of seals killed from the allowed 275,000. Let's hope that number will not be reached, and that next year the number will be zero.
When I get back I will have the photos of my trip to share... hope you come back on the 28th when I start my new rotation in the MICU. I've heard the patients are really sick, and there's a lot of work to be done, and a lot of learning to be had! Plus a lot of interesting stories waiting to be told...!
I came into work this morning at 0800 to find one patient on the board. One of my EM colleagues was working the 0700 - 1900 shift, and he was the only resident there. He told me the board had been completely empty when he took over. It stayed at one for about an hour an a half. Well, the pediatric side of the board did.
At WCHOB it's Women AND Children's, so we get adult females too. However, during the time that we rotate through the E.D. here we are not expected to see anyone over the age of 21. So, there's always an adult medicine attending who comes down and sees those patients. And, for the first couple of hours of my shift, they kept her pretty busy. In fact, I didn't pick up my first patient until almost 1000.
I saw a total of five, yes, five patients during my 10 hour shift today. Partially because a lot of patients didn't come in, and also because we added the PA during the morning, a fellow at 1100, another resident at 1300, and another resident at 1600. So, we had tons of people fighting over a handful of patients. I had three that kept me occupied all of my shift, so I didn't really mind that I wasn't seeing the other runny noses and fevers that were coming in.
I had a 5 year old with pyelonephritis (kidney infection) who came in with 2 days of fever, vomiting and back pain. The PA (physician's assistant) in the office thought she had appendicitis and had wanted us to do a CT scan. We "dipped" her urine after a complete history and diagnosed the pyelo. I spent the day breaking her fever, fluid hydrating her, keeping her comfortable with pain medications, gave her a dose of IV antibiotics, and then made sure she could drink juice and not throw up before she went home. She went from a whining, crying inconsolable little girl, to a perky, demanding spoiled little girl, albeit a bit sleepy from the tylenol with codeine, but still.
My next patient had dacryostenosis. I carried the little 11 day old up to my attending and told him this was how I was going to present patients from now on. Kind of like Show & Tell. Everyone oohed and ahhed over the baby, and I just wanted to know what was wrong with him. The attending took one look and gave me the diagnosis. Now I know. It's actually very common and very treatable, and I had the mother in and out of the ED in less than 20 minutes.
(**Oh, and no fair reading the prior comments... add your own before looking at everyone else's.... :D )
Next was the 4 year old that was told by one of his friends, maybe dared is a better word, to jump off the top bunk. He did and hurt his ankle. His mother said that he couldn't initially walk on it, but he seemed to be doing better today. We took films and initially thought he had a break but decided to wait for the "official radiology read." This ended up taking almost an hour. We tried paging the radiologist, which took another 45 minutes. Finally, I went up to radiology only to find that the attending was "getting a quick bite." Twenty minutes later, I finally was able to sit down with him and review the film. No break. Ace wrap and a week off of gym for this little guy. And, a warning not to jump off of any more bunk beds.
I don't mind being a patient advocate. Especially when there's a young child involved who sincerely just needs a simple procedure (like a tonsillectomy) to solve all of his problems. I spent four hours on the phone trying to arrange an appointment with ENT (Ear, Nose and Throat, or Otolaryngology) or try to find an ENT willing to operate on a patient with no insurance. This little guy's parent fell into the, we don't make enough money or have the kind of jobs where we can have private insurance, but make too much money to qualify for state or government aid. Finally, the Social Worker and Finance Planner were able to work something out with Catholic Charities, who would pay for the entire surgery except for the anesthesiology bill. The mother could prorate and get a payment plan for that part. However, it was near to impossible to find an ENT willing to do the surgery mostly because there are tons of roadblocks to even get in touch with one. But, luckily, the insurance thing is going to be worked out as of May 1, and I got him an appointment for May 15th. When I called the mother and told her, she said, "Is that the best you can do...?"
Deep breaths, in with the blue, out with the green. Say to yourself a hundred times, "I will not become a sullied, evil, people-hater who is cynical and burned out before I graduate from this program." And, remind yourself, again, why you're not a surgical resident... why is that again...? At times like this I wonder....
Finally, I had the longest patient in the E.D. A little 1 month old with a hydrocele. I thought it was one. My attending thought it was one. The patient's primary thought it was a hernia and wanted a surgery consult. When surgery showed up 3 hours after I called the consult because she had 8 other consults, and after I had already ordered an ultrasound which confirmed it was a hydrocele, I already knew that the patient wouldn't be going to surgery and would be sent back to their primary's with a diagnosis of hydrocele, I remembered why I wasn't a surgery resident any more... Because once I discharged this patient at 1800 I got to go home. Clocked out (well, not really). Hasta la vista, baby!
Grand Rounds' Wednesday tomorrow and then the weird 1600 - 0200 shift.
95,900 seals killed to date. Free the Farley Mowat!
Daffodils are Yellow for Hope!
Ok, So I worked Saturday and Sunday, but I didn't post anything on those days because on Saturday I came home to later find I had the stomach flu. I thought I was tired enough to get a good night's sleep, but of course, that didn't last long as everything I'd eaten over 24 hours was violently expelled from my body - several times over, so I got very little sleep. Sunday, I was recovering from working with little sleep and frequent bathroom "breaks," but the patients never stopped coming, and I actually ended up working an hour past my shift just trying to dispo (admit or discharge) my patients. So I came home to crawl into bed... for as long as that would last...
Luckily I had today to recover. I think everyone should go on a 48 hour fast. It will be so much easier to keep my diet this week as the mere sign of food makes me nauseous, and even the small amount I ate at dinner tonight feels like Thanksgiving dinner. So, it's small sips of clear soda and maybe some soup for me.
I direct your attention to the title, because no matter how often I and my fellow residents wash our hands, hold our breaths, or try not to touch anything in any of the rooms, we all get sick on the pediatric rotation. Kids are amazingly savvy about sticking their fingers in various parts of their bodies and then touching every conceivable surface of a room. Then, to further mark their territory, they seem to aerosolize all of their germs as well. Sigh. We just keep saying at least our immune systems will get tougher...
Anyway, let's see what we've missed over the last 2 days:
- tonsillitis
- mental status changes in an HIV patient who'd acquired it from his mother, he's also now developed lymphoma and gets chemotherapy, the most he would let us do was a CT scan (no lesions), he gets chemo again on Thursday, and they plan to admit him and get all their tests then, he's 18 so there's no holding him against his will, even though he's probably very sick, we had to let him go
- reactive airway disease, aka 1st episode of wheezing but not asthma
- hematuria (blood in urine) in a 15 y.o. who had perfectly clean urine when he got tothe E.D., strange
- "toe strain" which I didn't even get an X-ray for, it would make no difference if it was broken or not, I still would "buddy tape" the toe with its closest mate and tell them to take the tape off in a week
- enlarged lymph node in the neck
- asthma exacerbation
- 5th MCP (metacarpalphalangeal) Salter-Harris II fracture; in regular terms, he broke the hand bone of his pinky finger across the growth plate when he fell down while rollerblading, I advised wrist guards next time he goes out
- vomiting, when we don't know why, and the baby is able to drink and keep down fluids before we let them go, we just call it what it is, adenovirus season is coming up, and this may signal the start of it
- costochondritis, kids usually don't get heart attacks, so chest pain in a pre-teen is usually just an irritation of the chest wall ribs and cartilage, his story was good for it especially when I pushed on a certain part of his chest and he said, "Ouch! it was just like that!"
- gluteal abscess which I am bummed I didn't get to drain, we called for a surgery consult (which used to be me and this is the nice juicy type of abscess I enjoyed), however, it was the end of my shift on Saturday, and I was really tired, so maybe I wasn't so upset after all....
Sunday started off as kind of an "Urgent Care" kind of morning with quickie cases and resolutions, which was a good thing because my stomach bug was getting into full swing:
- strep throat, we (the residents) do our own rapid streps in the E.D., and I had done many, all negative, this was my first positive and I was actually excited to see the double bar on the test strip, a diagnosis is always pleasing
- anal fissure, seriously, kids (and adults) need to have more fiber in their diets, less constipation and prevention of diverticulosis when you're older
- laceration on the eyebrow of a 17 month old, I patched it with steri strips and glue, she actually did very well, no more climbing chairs for her
- abdominal pain: I've told my colleagues I want there to be a separate institution that takes all 9 - 19 year old girls who come in complaining about abdominal pain because it could be anything, and we have several "repeat offenders" who come in constantly with undiagnosable pain, it can be everything from appendicitis to pregnancy (I've heard of pregnant 10 year olds) to endometriosis to constipation, etc. And, I can't say to my patients "suck it up" like I'd like to, that would be poor bedside manner, and I want all good evaluations on my rotations...
- asthma, admitted for hypoxia, he just couldn't keep his oxygen saturations up
- pharyngitis
- vomiting, when you're sitting there all "blinged out" with a $250 dollar baby carrier, cell phone, double "ginourmous" pairs of gold earrings and bracelets to match, with the designer purse and you tell me you stopped giving your baby the "good" formula because it was too expensive, I am not going to be very sympathetic, spend less on clothes and more money on the baby, and don't explain to me how you're waiting for WIC to kick in because then I'll just be thinking about how my tax dollars are paying for you to text page your friends with updates... yeah
- reactive airway disease with hypoxia, my last patient of the night, poor little guy just wasn't getting better despite multiple treatments, we had to admit him, I just hoped he wouldn't need to be intubated because he was having such a hard time breathing, and, again, I wondered about the possibility of a need for a passing score on a nationally mandatory exam prior to allowing someone to have a child... don't even ask, I was already grumpy and not feeling well
I had today off and I did very little. I am on vacation next week and I had a pile of laundry and cleaning chores planned. Those will have to wait until later... it's off to bed with a little more club soda to keep the intestinal bugs at bay. Day shift tomorrow. We'll see what the morning brings.
On another note, I saw a great quote that's had me thinking, maybe you can all comment on what it means to you:
Senegalese Proverb: Every morning when the gazelle wakes up and sees the rising sun he has to think to himself, I must run faster than the fastest lion or die. Every morning when the lion wakes up and sees the rising sun he has to think to himself, I must run faster than the fastest gazelle or die. So, whether predator or prey, when the sun rises we must all run as fast as we can.
And, finally:
44,350 seals killed so far. The EU commissioner is very close to making a decision about banning the import of seal products. Let's hope it passes!
So, my shifts are 10 hours' long. Usually I come in at the beginning of the shift and pick up a chart and get to work. Within the first hour I have 3 or 4 patients I am working on, and over the next several hours, I discharge one, admit one, pick up another one, etc. I had 3 patients that I picked up within that first hour that I worked on over the next 5 hours.
The first was a little seven month old that needed to be evaluated for seizures. He had been having tremors or shaking spells for his entire life. He was born a few days late. His mother "failed to progress" after being induced and had to go for a C-section. When they finally performed the C-section, it was noted that there was a knot in his cord. How long the not had been there is not known, but there was some underlying concern for poor oxygenation during the end of the pregnancy.
His orders: CT scan of the head, basic labs, neurology consult. Seven hours later, I discharged him home with a normal CT scan, normal labs, and he will follow-up with neurology in the morning after he gets the results of an EEG (brain wave analysis) which was performed prior to his being discharged from the ED. Dx: seizures. Even though it's not official, we still have to call them that based on the description.
My next little 4 year old was having problems breathing. I got labs, put him on oxygen and we got a chest x-ray. His chest x-ray showed that his lungs were hyper-inflated (over-inflated) meaning that his airways weren't open enough to allow air out. He got a breathing treatment, but he still could not maintain an oxygen saturation above 92%. You need a 95 or 96% to be allowed to go home. And, he just looked sick. He got admitted.
Next came the 5 year old, also with low oxygen saturations. She had just not been feeling well for 3 - 4 days and went to see her doctor on Thursday after having a fever of 103 on Wednesday night. She had an oxygen saturation of 95%, and a chest x-ray was obtained. It showed a right middle lobe pneumonia. She was given antibiotics and sent home. As soon as she took the first antibiotic, she started throwing up and continued to do so all night and into this morning. They called their pediatrician who said to go to the E.D.
My expectation, and my attendings, was to get a repeat chest x-ray, give her some fluids and a dose of antibiotics. As soon as we saw the chest x-ray, we knew things were much worse. She had a fulminant pneumonia which covered about 2/3 of her lung, but worse, she had an effusion (fluid collection) as well. So, she was pretty much functioning on only 1 lung. We then had to go back and draw labs, blood cultures, and I got her admitted. We ended up doing a CT scan which showed a LOT of fluid around her lungs; so much that part of the lung was being compressed and damaged. I consulted the surgery service, and they will most likely need to go in and drain an empyema (infected fluid collection around the lung.) Very cool to do, but will not be much fun for this little one.
I also saw:
*wrist and elbow fracture - splinted and sent home
*sickle cell patient with pain in a shoulder after an immunization - antibiotics for possible infection, pain meds and sent home
*teen with abdominal pain that had been going on for 6 weeks and had undergone multiple CT scan, ultrasounds, and even exploratory laparoscopy with no diagnosis. When I left they were considering appendicitis, and she was going to be admitted after she underwent ANOTHER CT scan.
And, I think that's about it. Not a lot of patients by any means, but sometimes it's the quality and not the quantity that makes for good learning experiences. And, I have to admit, I am learning A LOT on this rotation. Off to sleep and back again tomorrow. We'll see what a rainy Saturday afternoon has in store.
Four out of the nine patients I saw this shift came in with a complaint of fever. We usually say that anything over about 101.5 is significant and should be seen. As I commented in a prior entry, it seemed as though all fevers coming in were 103. Tonight, at least I got some variety. Anywhere from 100.4 to 105.2 (yes, that last one is correct, it was recorded in the hospital ED).
So, our main job when a child presents with fever is to find out where the fever is coming from. Usually we have a visible source (runny nose, cough, vomiting & diarrhea, infection in the ears, etc.) But, sometimes a child just has a fever, and it becomes our job to rule out all of the bad things that it could possibly be: bacteremia (infection in the blood), meningitis, etc. All of these involve large scary needles. And, in my case, learning to do procedures.
I did my first successful lumbar puncture (LP or spinal tap) on my 15 month old with a fever. It was nearly a "Champagne Tap" but a few red blood cells sneaked in there, darn it! I got the spinal fluid on my second pass, and I honestly think the blood came from my first pass which was unsuccessful. However, I got the tap, and that's what counts most. Also the fact the child did not have any signs of infection in their spinal fluid. We can't forget that.
Also, today I got my first official thank you from one of my patients:
Dear Nurses and Doctors, I liked all the nice things you did for me. Ainsley
(In case you can't tell, that's a picture of me at the bottom.)
Today I saw:
constipation - seriously, these kids need to eat more veggies
ulcerative colitis in a 17 year old - I really feel bad for this kid. It's a horrible disease and the consequences of it are going to affect his entire life.
abdominal pain - seriously, if it's anywhere from 7 to 10 out of ten pain, I want to see you writhing on the bed and crying, not sitting back, asking to eat a sandwich and telling me "it hurts so bad."
fracture of a metacarpal bone in the hand - broke it on Easter Sunday, didn't think to get it seen until it was probably re-broken today. I splinted it and he'll see ortho in about a week.
jaundice - my second case, a 3 day old, very yellow, immediately placed under lights
and my 4 fevers.... the last was still being seen when I left, so I will find out tomorrow what happened. The other three were discharged and will follow up with their pediatricians.
And, that's it for tonight's patients. Or, last night's patients since it's almost 2 in the morning. I have my next shift tonight, and we'll see what the evening brings.
Overheard in passing:
- dog bite to the face, plastics came in to see
- broken tibia/fibula - ortho came in to see, and set in the ED
- domestic dispute and father got so angry he lifted the couch on which a 4 day old was lying, and the infant fell to the floor. He was being seen and will probably end up with a CT scan.
Here's my seal pic for today. 2900 seals out of the allotted 275,000 have been killed so far. The seal hunt was suspended un-officially for the last week, and it is set to resume tomorrow. Thick ice and fog may be keeping the sealers away for another day. The price per skin has fallen, and there's reports that even more sealers may chose not to participate as the cost of fuel has risen. However, the hunt has now changed to the area of the Gulf of St. Lawrence and "the Front" where the majority of the killing is usually done, so numbers of seals killed are expected to rise exponentially in the next several days. With continued pressure on the EU to ban seal skins & products, hopefully an end is in sight.
Since it's Grand Rounds Wednesday and not a clinical day for me, I thought I would take a few minutes to highlight the photographer for the majority of the seal pictures I have been using to make the graphics on my blog the last several days.
Nigel Barker is better known as a judge on "America's Next Top Model" reality show, but he has been a fashion photographer for many years after having been a model himself. This year, the Humane Society of America named him as a spokesman for the Protect Seals 2008 Campaign. The pictures I have used come from his website Nigel Barker and the ones that he shot which are used on the HSUS.org website.
He traveled to Newfoundland to visit the harp seal nursery and took amazing photos, then returned a couple of weeks later to catch the "molting" fluffy white pups. Unfortunately, his last entry chronicles the return trip several days later when he captured images of the hunt.
As an animal lover, and junior photographer, I hope there will come a day when trips by boat to Newfoundland and the Gulf of St. Lawrence carry eco-tourists instead of hunters, because I certainly will be one of those that signs up to see what must be an awe-inspiring sight.
Tomorrow, it's back the ED for my next block of shifts. The schedule will be more physiologically tolerable, a pseudo "swing shift" from the early afternoon to late evening. We'll see what the day/night brings.
Stickers are like gold in the pediatric E.D. I don't remember ever being that excited about them when I was growing up. Around 5th or 6th grade, I got into the girly "Hello Kitty" thing with the cute pencils and erasers (mind you this was the first "Hello Kitty" era in the late 1970's.) But, I really don't remember having a thing for stickers. Kids today, though, love them and actively seek out their favorites.
Unfortunately, we can't heal everyone with stickers, but sometimes it's the best gesture you can make after what these kids go through.
#1 - Foreign body in nose: "I wanted an adventure." 4 year old that decided to stick a rock up his nose. A few problems with this:
a) he lost the rock in the nose and couldn't get it out
b) he didn't like the idea of my sticking a tube in his nose to get it out
c) the "rock" turned out to have been made by a rabbit
- Sponge Bob stickers for him and some antibiotic ointment for his nose
#2 - Hand injury: 13 year old that got beaten up in front of her house by the neighborhood female bully. Supposedly. she lives in a very bad neighborhood, and there's a family that moved in that has caused a lot of problems. This is just the latest. The police report showed that after the girls started fighting, a social worker tried to pull them apart and she was struck and injured, and then more family members jumped in and there was a bigger altercation. Not to mention the reason why there was a social worker at the house: the mother is, to quote one of the ED RNs "Dumb as dirt." There are 4 other children in the house, one of which has cancer, and the mother can't be counted on to assist in his treatment (ie: remember to give him his medications and get him to doctor's appointments for chemo.)
- Princess stickers will help this poor girl feel maybe a little like a kid; she's having to grow up very fast.
#3 - chest wall contusion: 16 year old playing basketball got hit with a knee in the chest as he was bending to pick up a basketball during a game. No stickers for him; he's a little too old for them, althoughI might have given him the Spiderman one just cause.
#4 - possible sexual abuse: this was the hardest case of my night. I had to talk to and exam a 2 year old whose family was suspecting sexual abuse. Seems the little girl spends 2 weeks at her father's and 2 weeks at her mother's. Her mother has a boyfriend, and the father's family was concerned that this was the person abusing her. I had to take statements, do an exam, and call in a report to Child Protective Services. I don't know if I can follow-up with a case worker or not, so I will just have to follow her medical records to see if she pops up again.
- No number of Princess or Dora stickers could make up for the fact that I had to do a vaginal exam on a child already suspicious of anyone trying to have anything to do with that area. I can only be comforted by the fact that she's safe... at least for 2 weeks while at her father's.
#5 - #10: The usual montage of diarrhea, constipation, vomiting and diarrhea, etc. I do have to make one comment: if you're going to tell me that your child hasn't been able to eat or drink anything for two day because they throw everything up, do not hand your child a soda bottle and allow them to drink half the contents in front of me while you are telling me this. I might not believe you. And, when I ask if the child seems to be doing better, don't tell me, "No, she spits up everything she drinks down, " while the child is happily swinging her legs in the chair, sucking down her bottle of pop, and play burping along with me. Seriously, I'll wonder why you came, and you'll be left wondering why I am not doing a million dollar work-up on your child.
This was our ED whiteboard at 2030: we didn't clear it until almost 2 in the morning - and this is with 20 rooms, 2 surgical rooms, a trauma room, and an ortho room - all full.
Ok. Enough of being a vampire. Tomorrow is Grand Rounds Wednesday, and I am presenting the chapter on Pediatric Cellulitis to my reading group, so I better go read it. Back to the E.D. fun on Thursday.
Save the Seals!:
I bought a bunch of these small notebooks when I started this residency. Actually, a total of 6, two in each color. This is the first one, and I have its mate sitting in my white coat out in the car. As a part of our residency program we have to do a "follow up" on a certain number of patients that we see in the emergency department. We want to see "how well we did" in managing their care.
So, I carry my notebook, and every patient I see goes into it. I log down what their presenting complaint was (why they came into the E.D.), what I did (labs, x-rays, etc.), and what their dispo was (dispo = disposition: admitted or discharged.) It's also where I keep track of any procedures I performed: suturing, chest tubes, central lines, intubations, all of my 16 deliveries, etc. We have to have a certain number of procedures to be deemed "certified" and able to perform on our own without supervision.
Usually, I have my little book next to me when I am blogging the past shift's events, but... I left it out in the car, in my white coat, and I am feeling very lazy. So, I thought I would give some general comments about my shift last night:
- again, we were very busy. I think around 3 in the morning, we finally had no patients waiting in triage. Then around 0305 the next patient arrived.
- I am starting to feel like all pediatric thermometers are set at 103.something. I had 2 patients yesterday, and have seen several others, who all had home reported temps > 103 and who had temps of 99, 100, 101 by the time they arrived in triage. Ok, so maybe the Tylenol or Motrin finally kicked in, maybe the fever was at its peak and broke, maybe the trip to the ED in the crisp cool Buffalo air brought the fever down, but still. The kids shouldn't be nice and dry, playful and alert, etc. if they've had that high a fever. Of these two patients, one ended up with a respiratory viral syndrome, and the other I will have to find out about today as I had to sign them out when I left last night.
- I have come to realize that I am no good at math. Everything in pediatrics is mg/kg or ml/kg. Aside fromthe fact we're working in the metric system, and I have to consciously convert Centigrade to Fahrenheit, I just seem to have a mental block when it comes to simple multiplication. Not to mention that I also don't know, off the top of my head, the maximum doses of all of the medications we give (luckily I have my attending and a slew of nurses to remind me). So, it's been quite the challenge when I am called to give a medication order. Which I do, obviously, quite often. Sigh...
- If you're jumped while leaving a bar at 3 in the morning and knocked unconscious, you probably should come into the ED. When your face swells up and looks like Quasimodo's, probably a good time to get that checked out. You shouldn't pop a couple of your buddy's 'pain pills" and then go out to a BBQ with your blurry vision and massive headache. Just not a good idea. Luckily, when his parents finally found out, via an uncle who went to the same BBQ, they made their son come in to be evaluated. Luckily, the CT scan only showed a small fracture in one of the nasal bones, but things could have been much worse. My excitement, of course, was in dealing with something other than vomiting, fever, diarrhea, and, "oh, what's this rash?"
- when you come to the E.D., it is not necessary to bring your "posse" or "entourage" with you. The rooms are small, I am trying to get information, and I don't really need a running commentary or additional information from your supporting cast. There's a rule that only 2 people should accompany any one patient, but somehow others always seem to slip past the front desk, and usually our staff is too busy to notice the comings and goings and exchanges. I don't mind playing to an audience, just not while I am trying to take a history.
- little boys seem to get constipated an awful lot more than girls
- and, finally, there's something about sitting back during those brief moments of "down time" and listening to the "war stories" the nurses exchange with each other. Last night, the comments focused on pregnancy and all of the events that had been witnessed: some funny, some sad, some a testament to my sometimes thoughts that we should adopt a national "contraceptive" vaccine that doesn't allow you to procreate until you've reached a certain age, achieved a passing score on the "baby test" (kinda like your driver'stest, but you're only allowed to fail it once), and passed several rigorous written exams; after which you present with a folder of references and recommendations by others who are nationally certified to procreate. If only...
Ok, off to my last night of being a vampire for a while. We'll see what the evening brings...
When I left the ED at 5 a.m. this morning (an hour late), there were still about 5 patients waiting to be seen.... and a full board. This was the result of the backlog that occurred from earlier in the day. And, the fact we went from 2 attendings down to 1. And, the fact we had numerous ortho injuries requiring procedural sedation, which I will explain later.
At start of shift at 6 p.m. yesterday, I had two patients which my colleague signed out to me as he finished his shift. As I picked up new patients, I felt like I was wallowing my way through a pool of mud and having a hard time reaching the other side. Just when I thought I was finally getting caught up, something else would come up to stop the process.
Things should move faster... but I am going to save my rants on the other residents for a day when I don't have clinical duties and can editorialize more fully. As for now, into the melee:
Dx: Torn frenulum - 20 month old who came in with bleeding from the mouth. If you pull up your top lip, there's a small piece of tissue that forms a connection from the back of the lip to the gumline. You might even be able to run your tongue right up the middle of your top teeth and over the gums and feel it. This is your frenulum, and I learned yesterday that it is common in children to sometimes pull or separate and then bleed. As soon as I opened this young one's mouth, I saw where the bleeding was coming from. And, yes Mom, these bleed a lot. Your head, not surprisingly has a lot of blood vessels, and they bleed a lot. Tx = treatment, place pressure until it stops bleeding.
Dx: Dehydration - 9 year old who had his tonsils removed and became nauseated so he couldn't eat or drink anything then started vomiting. It becomes a viscious cycle: nausea then not drinking, vomiting, not drinking, more vomiting, then you find you can't or don't want to drink and you get dehydrated. Tx: IV fluids and admission to the hospital.
Dx: Ankle sprain - 10 year old who fell off of his skateboard and landed on his ankle the wrong way. Tx: wrap the ankle with ace wrap, crutches for a few days, and no gym.
Dx: Shortness of breath - 10 year old who suddenly "couldn't breath" while watching television with her family. These are difficult cases because "there has to be something wrong." You go into the room, the patient has no clinical signs of being ill, the vitals are all normal, and, as the child begins to describe what happened, you start thinking in your head "panic attack" or "attention seeking" you know you are setting yourself up for catastrophe if you don't start really focusing more on the story. Luckily, that's where the attendings jump in as you're telling them the history and say, "yeah, probably from hyperventilating during her panic attack." However, you get the chest x-ray or blood sample just to, honestly, appease the parents, and maybe assure yourself, that there really isn't anything wrong. Tx: none, come back if it happens again.
Dx: FB (foreign body) removal. Actually, I think this was my feel-good, pat my own back, moment of the evening. A 4 year old shoved tissue paper in both ears. When the mom found out, she took her to the Family Medicine doctor who was unable to extract the tissue. They prescribed some ear drops for pain and gave them a referral to the ENT specialist. They came into the ED last night because the pain was becoming unbearable. One piece was very deep, and I was able to extract it. The second was easier. They were my trophies. No one else appreciated it, but I did my own little victory dance and praised my steady hands. Woohoo to me. I know you may think this wasn't much, but seriously, I needed a little fun in the sea of pediatric misery that was last night. Tx: counsel patient to not put anything bigger than their elbow into their ear.
Dx: Salter II, distal radius fracture. 10 year old out rollerskating at a friend's party who fell and broke his forearm at the wrist. He needed procedural sedation (used to be called conscious sedation - basically giving medications to place a patient in a "twilight" state so that they can have painful procedures performed with minimal discomfort. One of the drugs given actually has an amnesiac property, so the procedure part is usually never remembered) which my attending supervised. He got his cast and will be followed in the ortho clinic.
Dx: Pityriasis rosea - 18 year old with a "rash for a month." Her friendtold her it was scabies, which is a parasitic, highly-contagious disease, but I assured her it was a self-limiting rash that would get better on its own. Tx: Benadryl for the itching.
Dx: LWOBS - left without being seen. Some people just can't wait any longer... they'll be back I am sure.
Dx: Newly diagnosed diabetes mellitus - this was probably one of the more interesting cases last night. An 8 year old who suddenly started drinking large amount of water and was urinating "more than was possible for a little boy his size." He'd been doing so for about a week, but yesterday had suddenly become more tired and shaky. Given the story, we immediately suspected diabetes. A fingerstick glucose was >500, which is the meter's highest setting. The lab recorded his glucose level at 743. Given the top normal for a non-diabetic is about 120 for a fasting level, this was just a little high. Yeah. He was immediately (even before we got any labs or levels) started on the diabetic ketoacidosis protocol and given fluids. He was admitted to the endocrinology service who will get his blood sugars under control, give the family a lot of teaching and education, and start to learn how to live with the disease.
Dx: minor head injury. 10 month old who flipped himself out of his playpen and onto his head. No injury, just a little bump on the forehead. Tx: monitor for signs of further injury.
Dx: dehydration - 17 month old with vomiting and diarrhea for a week, and not able to eat or drink. Now, I have to editorialize just a little on this one. His parents both looked like they were in their very early 20's. Not together since this was "dad's week" with the young one. When I asked why they had waited so long to get medical care since this had been going on, and the baby hadn't been keeping anything down at all, the mother looked at the baby's father and said, "Because he just told me about this." They weren't able to tell me how many diapers the baby had wet, did he have tears when he cried, and when I asked if they had given any sort of Pedialyte, the dad answered, "Well, I gave him some sips of ginger ale." The dad's only concern was, "Can you give him something for the cough that will knock him out?" House would say, "Um, no, I'm going to give him some IV fluids so that his kidneys keep working, his heart is under less strain, and so his eyes stop having this reddened sunken in look." I, of course, tried to politely explain that ginger ale is not a good idea and Pedialyte is a better choice. Tx: IV fluids and parent education.
Dx: chronic otitis media, I think - I actually had to sign this one out to the senior resident when I left this morning. A 4 year old with cerebral palsy, chronic seizures, who went to another hospital with a fever of 103 and was found to have "some kind of infectious process" due to a high white cell count, who subsequently got transferred to us because "we're the experts." This poor mother had been up since the day before and would soon have to drive back home with her daughter since, when I left, we weren't planning to admit her. I'll have to see what happened.
Whew. That was my 10, no 11 hour shift last night/this morning. What I want you to realize, and I know I've said this before, is that I don't see the patients one at a time. I see one, present it, start the workup, then go see patient two, present it, start the workup, check if labs/films are back on patient one, go see patient three, call a consult on patient two, check labs on one, start admitting two, see patient four, etc.
Given that we were so busy last night, the time between seeing and presenting a patient was sometimes as long as 45 minutes. Meanwhile, I am not allowed to see another patient until I have presented my most current. This explains some of the wait encountered. I could have probably seen 3 patients while I was waiting for my attending to come out of the procedural sedation room, but we're just not allowed at this point in our training, which, really isn't a bad thing. I know I still have a lot to learn.
Patients overheard but not treated by me:
- a patient with Henoch-Schönlein Purpura which is a trio of rash, kidney involvement and arthritis that is caused by an autoimmune response.
- as predicted 2 or 3 victims of the Hockey USA tournament being held in Buffalo this weekend. I saw the films on one of the boys with a broken leg... ouch!
- a girl who'd been bitten by a dog. Plastic surgery was consulted to help repair the damage
- a child who might need an amputation of one or more of their fingers, I never heard the story, but our 2nd year on the hand service came in to take the consult (that will be me a year from now when I do my ortho hand rotation).
That's it... off to enjoy two more hours' of freedom before my shift tonight. At least it's Sunday night... right?
Ok, so let's jump right into this:
The E.D. was busy and "standing room only" when I got there. We had so many providers (attendings, residents, and PA's) that I actually didn't pick up a chart for 1/2 hour. I got my bag settled under the counter (we don't get lockers, so it's first come, first served space), filled my lab coat pockets (scripts, pens, penlight, stethoscope, pregnancy wheel, etc), and pulled out the newest EM journal I brought to read "in case things were, hmm, not the S word or the Q word, umm.. "calmer" later in the evening.
Finally, I picked up my first chart: "toothache." Great. I looked at the clock. Six thirty p.m. on a Friday night is not a good time to be coming into the ED for a tooth complaint. I went off to see the extent of the damage and wondered what I might be able to offer.
It was a 7 year old who's mom had tried to get her into a dentist's office, but wouldn't be able to for another couple of weeks. She a had a cavity in one of her back molars that went all the way into the pulp of the tooth. Very painful. I went off to find my attending and to see what was able to be offered. Luckily, WCHOB has a dental service, and so I was able to consult the dental resident who came down and prescribed antibiotics, pain relief, and got her an earlier appointment. One down, nine more hours to go.
Since I am running late, I will briefly highlight what I saw last night:
13 month old who fell and bumped his head. Dad works in the neuroradiology department and sees what can happen with even minor head trauma. I examined the child, gave the parents assurances, and sent them on their way - Dx (means diagnosis) = minor head injury.
10 year old with left arm pain after falling while playing soccer. Dx = left distal radial buckle fracture. She broke her forearm bone close to the wrist. Splint for her, and she will follow up with ortho for a cast. No gym for 10 weeks.
13 year old with "nipple swelling" and left arm pain after getting into a fight at school. The nipple swelling was normal due to hormones. Dx = gynecomastia. The x-rays didn't show a fracture. Dx = left wristsprain. Ace wrap and ibuprofen.
18 month old with "nipple swelling." Actually, this little one did have an abnormal breast mass. By this time, it was almost 10 p.m. We didn't have an ultrasound tech in-house, and this wasn't an emergency. She will definitely need to have follow-up and probably a biopsy of the mass. We sent her out with instructions for follow-up with her pediatrician. If I get any follow-up I will let you know. Dx = breast mass.
3 year old with a severe asthma attack. This was my longest patient in the E.D. in terms of disposition. He ended up receiving 3 rounds of nebulizer treatments and his oxygen saturations never got any better than the low 90's. He ended up having to be admitted. Dx: hypoxia, asthma exacerbation.
2 year old who mother reports wasn't "drinking enough." We gave him some pain control since he'd recently had a tooth pulled, and then gave him something to drink, he did, so he went home. I honestly don't know the diagnosis since my attending was "cleaning house" when he came on shift and discharged the patient on his own.
18 year old with cramping and vaginal bleeding. She was just about 7 weeks pregnant. After no seeing anything on the ultrasounds and finding a lot of clots on my vaginal exam, we drew some blood levels and sent her home with instructions to return on Monday for a second set of lab draws. If the numbers go up, the pregnancy is still viable, if they go down, she most likely miscarried. Dx: threatened miscarriage.
And, finally, 20 year old with concern about STD exposure. Sex with Boy A who had a history of an STD. Then sex with Boy B about a month later. A couple of days ago Boy B said she'd given him an STD. I took cultures and treated her for STD's. I also advised her on the importance of wearing condoms and birth control.
And, that was it for patients. I am running off for another night of fun with the chillin's. Also, Hockey USA is in town for several tournaments. I wonder how much ortho trauma we might be seeing tonight...
**on a side note: I want to thank "D" (Donna) for including my blog while doing a stint as Guest Editor on the Magic Smoke blogsite.
Thank you, D!
As stated previously, this is my "turn-around" day where I try to reset my clock to vampire mode for an upcoming 4 nights of shifts long weekend. I took a long nap this afternoon, flanked by cats, and am now trying to keep myself awake by doing odd and end things in my office.
Nothing much else, so I won't bore you with any further musings today...
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In case you have been following the seal counts, I was wondering what had happened to the HSUS.org website since they hadn't done any updates, and I found out today that the seal hunt is being suspended for 7 days while memorials are held for drowned crew members of an overturned boat.
The larger hunt is looming just over the horizon, and I know the totals will start sky-rocketing then. Again, "Don't Buy While Seals Die." There's a nice letter to give to your grocery store manager if their store is still on the list buying Canadian Seafood on the HSUS website.
So, officially March 30th is Doctor's Day. This morning, BGH celebrated Doctor's Day with a breakfast. Since residents normally start the day with stale bagels, cold coffee or lukewarm soda, the thought of a nice freshly made omelet or Belgian waffle with fresh fruit topping appealed to all of us. So, before our morning reading group, we ran to the cafeteria to grab something hot. Along with breakfast, the hospital higher-ups gave us a gift of a small coffee thermos with the hospital logo engraved on it. I like it.
And, essentially, that was the major event of the day. We had our normal Grand Rounds Wednesday with the addition of Journal Club. Once a month, a topic is chosen along with a series of journal articles, and we read then discuss the relevant issues. Normally, we focus on current medical studies related to Emergency Medicine. Today's focus was on domestic violence and how we, incorporating the local EMS system, can more effectively screen patients. We talked about the pros, cons, logistics, and pondered the potentials for the future.
Yes, very heady stuff for a Wednesday morning. I had no clinical duties today, and actually have tomorrow off. I work a 4 day weekend (Friday - Monday) on the night shift, so I probably will drop a quick note the next 2 days along with the de rigueur Seal Photo of the day to keep reminding you that the hunt continues. I will post the events of my next shift on Saturday morning after I get home, and before I fall asleep for the day as I switch to vampire mode, yet again.
Till then....
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!
