Mid-way thru ...

Anyone who thinks Pediatrics is 'easier' has another thought coming. Younger humans have less developed anatomy and physiology, including immunity. Babies can get pneumonia. Peritonsilar abscesses can stay hidden behind enlarged tonsils. A 5 year old can develop rheumatoid arthritis. It takes a keen and careful eye to stay on constant alert. So far, I've done very well.

Something I've always heard as rote from others is "oh, I love the kids ... it's the parents that I can't stand!" For the most part, parents have been wonderful. There have been a couple of nightmares ... the ones who let their daughter crawl around on the dirty floor, the ones who smoke in the car with the windows rolled up. There was one couple with triplet boys ... when the boys were kicking the table they were sitting on, the mother told them to stop. They didn't listen and continued, so I said, "hey you guys, listen to your mom." She let off into me, telling me I didn't know how to deal with children. I was astounded, considering that I was backing up her attempt. Anyhow, they were spoiled kids and eventually she'll understand that ... or maybe she won't. That's the other part of Peds, you can do your best to help in any way you can, but in the end they leave and go out and live their own lives.

Do I still want to do Peds? Definitely. I have had so many good experiences so far, and learned so much. I'll be sad to see this one end. Next is a State Mental Institution that houses convicts who've had their pleas of insanity granted. Gonna be quite a change from cooing and gurgling babies.

The beginnings.

Doc had me see a 5 day old yesterday, I love those visits. Just checking things, making sure everything's working out. He then gave me a 6 month old patient with developmental issues. The infant was at the level of a 4 month old, with some musculoskeletal and other developmental issues. I noticed almond shaped eyes but ... anyhow, when we went in together, he showed me how it's done. He was very calm and cool, pleasant, and then asked, "so whose eyes she got, she got Daddy's eyes?" in his Italian way. The mother and aunt said no, and he just smoothly then asked if there had been any genetic testing? No. He said he wanted a CT of the brain, and that he also wanted to test for Down's. He broke it to them very coolly, basically. They were so down, it was hard for me. I noted her improvement since the report of the last visit, where she had obviously gained strength, but they kept shooting it all down as not meaning much. I disagreed with them, saying that it meant more than they were making it out as. You couldn't tell in usual ways when she was smiling and laughing, but she still made it obvious when she was. They knew that, and it was obvious that they still loved her very much ... it was just a big disappointment with daunting overtone.

So, I went into the big texts and looked up all the genetic defects possible. I searched and searched for anything else it could be, something less major. I searched my handheld device that I enter all the patients I see into, and searched for something like, 'developmental delay'', anything that could offer better hope. Well, when I got home I searched Down's syndrome and pulmonary issues, since the baby's lungs had sounded like bellows. Sure enough, a majority have them. So, I gave up and went back in and changed the diagnosis officially to Down's. It might actually be Mosaic Down's (she didn't seem to fit all the criteria for Trisomy 21), those individuals tend to have IQs 10-30 points higher than those with Trisomy 21. Either way, there's hope.

The whole thing was like the antithesis of the 5 day old who was the perfect little baby. Still, altho their lifespan is sometimes relatively short due to oftentimes having congenital defects, with therapy and work Down's children can grow into productive people all their own. Some go onto independent living situations. Some have even won best actor awards (Cannes, BAFTA). I hope I was able to impart some hope and caring to that family's darker day. I hope I get to see them again so I can relay all the information I've learned since we saw them.

Anyhow, I've worked in and around Emed for so many years now that it was the majority of what I knew clinically. But I knew by the end of my second day on this rotation where my calling lies. I had a feeling before even starting that this would happen, and it did. Not to say that I won't work in the ER as well, part- time. Anyhow, let me work on graduating and getting my license before I start working anywhere at all ;) But it's almost as if my appetite for medicine has been whet all over again. Not only do you get to practice medicine with all the age ranges up to adult, you get to work with their families. You're there to help drive an important point home that the parents have been trying to impart with their child not listening. And likewise, you're there to help block some of the blows parents can sometimes unwittingly impart towards a child who is simply beginning to explore life as a young adult. And most important, I get to cure pneumonia. I'm home.

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.