Pediatrics 101

I've been studying a mean streak over the past few weeks, in preparation for both my Peds and Psych rotations (I only have a 2 day break in between). I have been concentrating more on Peds lately ... there's a lot. In fact, my Textbook of Pediatric Care is substantially thicker (and with smaller print even) than my most impressive Emed text. 10 more days to go before I start, I'm really looking forward to it. I've always loved kids, and kids usually gravitate towards me for some reason.

I'm trying not to go into this with any preconceived notions similar to those I had when I volunteered in Pediatric ICU at a Children's Hospital years ago. Since I've always gotten along so well with kids, I had figured that it would be 'playtime', more or less. How very wrong I was. The children in those units are oftentimes very, very sick, and many others have chronic health conditions. It's almost a complete oxymoron, the Disney characters on the walls, attempting in complete vain to create an atmosphere of joy where there quite simply is little. Still, you do what you can, you manage a smile here and a cuddle there, and then you save your tears for when you're out of sight. That's not to say that there aren't happy times, from the 17 year old whose cancer went into complete remission to simply the good day the young tyke had when family and friends were present and videogames were played.

Of course, I don't think I'll be in ICU too often since I'll be rotating in a clinic. The clinic is in a more impoverished area of Philadelphia, I've been told I need to bring my own otoscope and opthalmoscope. I have no doubt that I'll be seeing my share of flus and assorted other viral incidents. But in reading through the material, many of the somewhat more serious conditions present so similarly that I'll be on the lookout with a keen eye. Granted, many are treated the same way, but there are a few that need more specific handling. I'm looking forward to the challenge, and the opportunity to make a difference.

All that being said, I hope I'm up to date on some of the current jargon ... is Dora the Explorer still the hip thing? How about Blues Clues, is that still even aired? Someone said SpongeBob, but honestly that came from a faculty member who's probably been saying that for years lol. I'll be able to talk movies with the pre-teens/adolescents, and I think my best bet with the infants is to bring some sparklie doo-dads, but I'm a bit stumped with the kids. Time to do some, er, research. Maybe Alvin.

Long day of hard work.

Post-cesarean pre-eclampsia (scary ... her BP was through the roof, but her pulse was really low ... the PA was unsure of what to do, we knew a beta-blocker wasn't the answer as it would have slowed her pulse down even more ... so I went and conferred with a doc who told me "hydralazine" .... I went back and told the PA who asked me to look up the lowest dosage ... she totally trusted me and entered the order right into the computer ... the Ob/Gyn doc showed up to the office door later asking for a PA, I told her I was a PA student, and she said, "Oh, no, I need a PA" ... I said, "is this regarding the patient with pre-eclampsia?" ... she turned back around and said, "yes" ... I told her that I had consulted with the doctor who had recommended hydralazine ... she said, "oh, fine, tell the PA I want it started now" ... I told the PA when she came back and she said, "I already did!" ... I was so proud! I can't wait until I don't need a middle-person to input the orders and I can do it myself, even more so when I don't have to consult and I already know the answer ... my day will come). Forehead laceration that I sutured and dressed. Esophagitis. A woman cut off her fingertip (we weren't able to save it and had to throw it out, but she didn't damage the bone ... man tho how a fingertip can bleed! My supervising PA had her soak it in hydrogen peroxide which slowed the bleeding quickly. I dressed it with gel foam and wrapped it up well). Ringworm (every inch of his body, poor guy). Achilles tendinitis. Dog bite (I cleaned it and steri-stripped the lacerations semi-shut, they were small, and then I helped the patient and her mother figure out what to do with the dog). Acromioclavicular displacement. Conjunctivitis. Took on a case that the doctor was surprised I wanted, a young woman who had been seen by a NP at a CVS Minute Clinic, where she had been diagnosed (incorrectly, as I ascertained) with a peritonsilar abscess and sent to the ER ... she simply had swollen tonsils from a viral infection, I can't believe the NP hadn't gotten it right away. The doctor came in later and said, "strong work" ... that was it, "strong work", then he turned and walked out.

Last day tomorrow.

:(

Two more days to go ...

Worked a 12 hour today thinking it was my last, but got a call from my preceptor telling me that I will be working tomorrow and the next as well. It's the 9am to 9pm shifts, which don't allow for much time between getting off work and going to bed (approximately one to two hours, if I'm getting a full 8 hours of sleep), but it's not impossible and I'm learning continuously. I was looking through a new PA review book, and I answered practically all of the Emed questions correctly (many because of my recent experiences). I'm actually looking forward to the exam coming up next week, I think I'll most likely do very well.

Today was jam-packed. Everything from a man who had cut himself on a goat skull that he was cleaning on Thanksgiving evening (???, I know) resulting in a pretty nasty infection, to a young woman with a ruptured ovarian cyst, to a man who had been cleaning his gun when it went off and took off two of his fingertips (we sent him to see a hand surgeon tomorrow, cleaned it up best we could and I rocked the splint and bandage, even the nurse came in and asked who had done it, she was so impressed), to a back abscess for which I changed the packing and dressing by myself. I did really well today/tonight, and worked with two PAs who treat me like a student, but also as a colleague. I was surprised today how much I knew ... one of them even asked my advice a couple of times, and another couple of times asked me what I wanted ordered and prescribed and trusted my judgment enough (making sure that I knew what I was talking about first) to input the orders before even seeing the patient themself. I realize that there is no official word "themself" in the English language, but as there is 'themselves' (plural), confabulating the singular feels right.

Feeling good! I'll miss this rotation when it's over, I'm hoping to go back towards the end of my clincial year for one of my 3 month preceptorships ... we have to have one in Family Medicine, but we can request the other be in Emed or Peds. So we'll see.

Just got home from a standard overnight shift ... fractured humerus, tendinitis, back pain, fractured femur, chest pain, etc. My last patient was a 4 year old girl with history of epileptic seizures and chronic respiratory and GI issues. She lives in peds ICU. She was sent down to the ER due to a febrile seizure, where I helped to monitor and care for her as her fever was brought down. I had seen a case similar to hers years back when I had volunteered in peds ICU ... kids with chronic issues can end up living in the ICU for long periods of time (even years), often not only due to their condition(s) but also to abandonment. Such was the case with this patient, except that her condition was compounded with neurodevelopmental damage from her history of seizures. She understood touch and voice and was somewhat able to communicate her feelings, but it was difficult for her to focus on any one object for too long and she can only utter sounds as her means of language. She is so used to having her respiratory secretions suctioned that she can hold the suctioning device and do it herself. As if her condition isn't tragic enough, it was even worse to learn that she hasn't had a visit from 'family' in weeks. After we took her back to ICU, I moved past the nurses and kissed her forehead and said, "goodbye beautiful". Her face turned up as her eyes attempted to focus on mine. One of the nurses said, "ohh, looks like someone has a boyfriend!" We all managed a laugh and then I went back to the ER where I went into the back office and cried. My supervising PA found me and told me to go ahead and go home an hour early.

It makes me feel ... both an appreciation and a hatred for my own life.

A couple more weeks left

After my last midnight shift for the week tonight, it'll have been a 72 hour week. I've enjoyed just about every minute of it. I've been suturing a lot more without supervision, and have done excellent work. One was an elderly woman who had fallen in her group home ... her hair was filthy, and she had bad odor. She had fractured her hip in the fall, and lacerated her eyebrow. It looked worse before it was cleaned up, but it was still in need of stitches. I evaluated the cut and saw that 3 stitches would be adequate, for this almost 90 year old woman who probably had few visitors and little to no chance at romance in her remaining days.

So I put in 5. She will heal without a mark.

Half way point

Last week went well. I observed some hustle and bustle around a patient with acute MI, but honestly other than that nothing too exciting. A metal worker came in and I tested him for corneal abrasion (yup). I sutured a lacerated ear by myself. I splinted a fractured hand. I listened to this crazy woman who said she was a nurse, tell me that she hoped her abdominal pain meant she was pregnant (let's hope not).

Something interesting that happened was that I diagnosed a patient with pneumonia after doing my history and exam and after seeing their x-rays, and my supervising PA and Doc both disagreed with me saying that it was simply viral flu. Lo and behold the report that had come back the next morning, "XXX DISCREPANCY XXX: PERIHILAR INFILTRATE FOUND" (meaning yes, pneumonia). What was cool was that the PA showed the report to me, I was proud of myself and my developing clinical sense. Then later on in the shift (around 3 am), we got a patient who had eaten some bad fish and whose temp had spiked to 100.1 and then gone down to normal. I told him that he had a simple case of food poisoning, that there are only a few organisms that we would really need to worry about and that if it was one of those he would probably still have a fever. I started him on fluids since he had endured some bad diarrhea (which had also subsided), and recommended that he go home and rest but to return if there were any other complications. Again, both the supervising PA and Doc told me that no way did food poisoning ever present with fever. So I went and got one of my big books that I lug in every day, and showed them that indeed it can.

As proud as I felt on both these occasions, I'm smart enough to know that I could just as easily be sitting on their side of the fence. As I have stated before, mutual discussion can sometimes be a really valuable learning tool ... we can't know everything, no matter who we are, and one of the most important things we can do is to always keep an open mind so that we continue learning at an optimum level. May I remember those words the next time my ego gets in my way!

7th day in the ER

Things have been standard. Lots of flu, learning how to distinguish it from pneumonia using basic tips such as if they have cough all the time or only upon breathing deep (if it's the latter then they can probably skip the CAT scan). I've been working with a PA of 7 years who was 40 when she graduated. It's sort of odd, because I usually come down on younger folk who have little experience but she had little experience and is really, really impressive (tho she did shadow a bit in the ER before applying). I don't know if it's because she was a mom, or if she just has the perfect personality to be a PA. She forgets nothing, her interactions with the patients are extremely thorough and accurate. I've always been one to notice error, and I'm having trouble find any with her. Anyhow, I'll be with her on two midnight shifts next week and I'm really looking forward to it. For the midnight shift, fast track (which the PAs run) shuts down and it's one Doc and one PA up front all night. They one-off it on the rooms, Doc, PA, Doc, PA, so the likelihood that I'm going to be learning a good deal and working hard is high. Looking forward to it!

So where was I, standards ... flu, back pain, finger lacerations, broken arms, sickle cell crisis, concussion. While I was checking out an eye for corneal abrasion, an alarm went off and about 18 people ran out into the lobby. An older man had sat in the triage chair, slumped over and died. This tiny female tech (she was must have been about 5'2") jumped up with him on the stretcher they got him on and was just seriously pumping away. Sure enough, about 2 minutes later, there was a strong pulse and everyone on the team had done a good job. I've been involved in resuscitation attempts before, but it was still good to stand there and watch the synchronization of the team.

There's been a DPM rotating in the morning with us, he's a Doctor of Podiatry (resident). He's been in school his entire life, I'm sure he's still in his 20s. He and one of the young PAs were looking through my Clinical Atlas of ER Medicine (there's lots of gnarly pictures in it), when I heard him ask her if she had ever seen KS (Karposi's Sarcoma). She said she had not, and I said that I had. I looked up and said that I had worked in AIDS hospice. The Podiatry resident said in a snotty tone with his nose turned up, "why would you do that?" I must have looked as confused as I felt, and responded, "why? to learn." It was a weird moment, where it hit me that not everyone is in it for the 'commonwealth of all peoples and nations', if you catch my drift ... especially not for those who are our nation's 'unmentionables'. Maybe I should have asked why he chose to work with smelly, stinky feet for the rest of his life. Anyhow, I chalk his comment up to reasons of immaturity as well as growing up. If anything, it probably made him think.

4th Day in the ER

Something interesting happened. I saw a patient, he was in extreme pain. He said it had happened out of the blue, as he was watching TV. He had been dealing with some URI symptoms over the week prior. Checked his ears, no pain in the pinna/tragus/mastoid regions. Looked inside, the tympanic membrane looked okay but then when I peered upwards I saw what looked to me to be a tear, with blood on its edges. I went back to my supervising PA, told her the patient needed pain meds asap, and told her I believed his eardrum had ruptured. She ordered him a percocet, and went in to check him out. She looked in his ear and said, "yup, you've got a perforated eardrum." The PA still called for a Doc to check it, in case there was anything we could have missed.

The Doc didn't come to speak with us, saw the patient and re-diagnosed him with acute otitis externa/media and specifically noted that there was no perforation of the tympanic membrane. When my supervising PA saw that he had changed the diagnosis, she went off. "What is he talking about? How could he say it's involving otitis externa, he doesn't have any outer ear pain and there's no sign of infection! The guy said it hit him like a thunderbolt, how does that history say anything other than a rupture? And the student and I both saw it! Plus he had a history of ruptured eardrums as an infant!"

So, the patient was sent home with prescriptions for steroid and abx drops. Now, steroid drops are contraindicated in tympanic membrane ruptures as they can slow down healing. The abx, there's no problem there since the patient should probably have them either way. I'm just glad that the PA told the patient to see an ENT specialist asap, in order to make sure of the final diagnosis. I know that my future will be bringing these types of situations, but it was interesting to finally encounter one first-hand. All that matters to me is that the patient is treated properly. I suppose I might have mis-judged what looked to me to be a tear, but as the PA saw it also it leaves me to think 'hmmm', you know? It was on the upper right hand top edge of the drum, so what if the Doc didn't see it? Then again, what if we both mis-judged, and the patient would have gotten inadequate treatment from our side.

I think that the key point I took home was that there were two conflicting diagnoses, but it was the PA who, even when she had made her diagnosis, still told the patient that he needed to follow up with an ENT specialist. The Doc did not. I'm not saying that their different licenses had anything to do with it, it could have easily been the other way around. But I do think it's better to be safe than sorry, especially in light of any disagreement or possible discrepancy.

2nd Day in the ER

Wow, what didn't I do. What an amazing day. Dropped a foley into a 94 year old man who hadn't urinated in 4 days. He's sending me information on his lifes work researching how the foods you eat can improve your eyesight. He said he had three doctorates but he also said that the President called him back so we'll see. I also got to cauterize a hole in a fingernail that had become infected after the patient scrubbing a pot had resulted in a piece of cooked rice getting lodged under the nail. Thankfully, my joke about going all the way through the finger went over well.

Other than that it was migraines, vision problems, serious back issues, drug seekers, psych cases, foot fractures, chest pain, just a really wide range of cases. I guess I'd have to say one of the best parts of the night was when one of the PAs asked me where I was thinking of working after graduation and then told me I should "keep in touch".

I done good.

First day in the ER

It went really well. I had some great PAs to lead me through, they started me off with a patient on my own the minute I got there. I saw a psych case, some musculoskeletal issues, and a lot of post-URI sinusitis ('tis the season). 12 hour days, but it went by really fast due to the constant volume of work. I'll only be on 36-40 hours a week for this one, and I get to sit down here and there so it's really looking to be a cool experience. I've been told to expect a good deal of suturing, and altogether a well-rounded adventure.

I'll keep you posted.