Thursday, October 30, 2008

Cross-eyed babies


Yesterday morning I got pooped on, spit up on, and peed on by three different babies. All before noon.

But still, I looooooove babies.

Too be fair, my hands are usually freezing because I wash them so much. Every morning I start my day in the newborn nursery checking on the freshly born little goobers. I have to check their soft spots, their hips for dysplasia, their boy or girl parts, and their eyes. I check everything, of course, but those are part of the special baby exam. It's when I check their boy parts that I have to be on high alert. Cold hands plus fresh air minus diaper equals whiiiiizzzzz. I have to have reflexes like a cat if I don't want to smell like a diaper the rest of the day.

One little guy had perfect hair straight out of the womb. He could have been a Catholic choirboy with that hair: thick, blond, and long enough to have a perfect little boy side-part. So cute! His mouth an nose were bruised though; I didn't realize how common that was. Apparently birth is traumatic for everyone involved. He also had crossed eyes. That's completely normal, at least until about 4 months. One of the first signs of development is when a baby's eyes track together. It means both sides of baby's brain are working together now! Knowing that cool factoid didn't stop me from giggling a little when I saw it. It was so precious. Plus, I had to pry his eyes open to see them, stubborn little guy, so his face was all scrunched up with anger. No, prying his eyes open isn't child abuse. I asked. It's how you have to do it unless you want to get the lid retractors (which sound worse).

Before I leave the nursery I say hi to every baby there, whether or not they are my patient. It means a lot of hand-washing, but it's one of the best parts of my day. I do the same thing with well checks--I always sneak a little extra squeeze before I give them back to Mom or Dad. I consider it my little perk for getting up early. Besides, we had a baby born in a Ford Fiesta in the parking lot the other morning, so of course I had to check that kid out.

Monday, October 27, 2008

Hey! Don't Give Me 'Tude!

Normal "Man" sign

New "Teenage" Man Sign complete with skinny jeans

Teenagers crack me up.

I had been lucky in the past with teenage patients. They come in with their little attitudes and their punky outfits, sassing mom a little but meekly answering every question I ask. One 15 year old I talked to looked just like my alter ego on Rock Band, rainbow hair and everything. I would have told her that, but figured that wouldn't mean too much to a teen and besides, my alter ego on Rock Band doesn't have a very classy name (the game will actually tell you that, in case you have no taste). Instead I said her hair was amazing and I should have done way more crazy stuff when I was in high school and it didn't matter. Dang I'm still jealous of that Fun-dip colored hair.

Today I switched clinics to an older clinic, meaning I saw a lot more teenagers and older children. Probably a good cure for the baby fever I caught at my last clinic. There were several patients today for whom a better description of their illness might be "Demon possession" or "OMG-my-life-is-so-dramatic-ism" (yeah I made that up).

One patient with false eyelashes and a haircut stolen from Elvira steadfastly refused to fill out her intake form. In between yelling at her mom and tugging at her Juicy sweatpants (with the writing on the butt, while we're on the subject of classy), she whispered behind the nurses' back that she didn't have to do it, then when the nurse would turn around she'd lift the clipboard up and make scribbles as if she were. Apparently her dad owns a few small businesses in town, so she gets to act like an ass every time she comes to the clinic.

She wasn't the only one yelling at her mother either! Two other teen girls in clinic today told their mothers to shut up! Multiple times! Now, I don't know if all you readers have met my mother, but let me tell you this: if I said shut up to her face, she would wrestle me to the ground and teach me a lesson. And I'm 25 years old.

I will be the first to admit that when it comes to teenagers, I'm over the hill. I try to remember one rule when dealing with them: They are the oldest they've ever been, and they think that's the oldest they'll ever be. The world revolves around them and their friends. That's just how it is; they don't know any better. Their frontal lobes are not developed enough to engage in the sort of planning and forethought that most of ours are now able to accomplish.

Now, personally I don't think that excuses such phenomenon as boys wearing lady jeans (especially in a smaller size than I do-makes me want to kick their tiny little hinys), or man-scara, guyliner, crying in public, excessive touching, forming enormous giggling groups and parking themselves at the movie theater entrance so I have to walk through the cloud of AXE and sex hormones, but it's not like I run around Sonic parking lots with a broom yelling "Tarnation" either.

Part of being a good doctor is realizing you have a filter through which you view your patients. Most of us are perfectionists, a lot are a little egotistical. We spend a decade learning how to do things The Best Way, and can't understand why patients don't always see it like we do. In order to treat patients effectively, you have to learn to set aside that filter and see from their perspective. Even if you think they are drama-crazed hormone-mongers. I just hope I have more patients like Cool Hair Chick, and fewer like Tramp-ola. And crap I hope I didn't act like that in high school.

Wednesday, October 22, 2008

So much fun I nearly puked.

Last night I was in the OR for three hours. One of my preceptor's patients showed up at the ER with an MRSA abscess and a fever. She called a surgery consult, and in the OR that night we found out the pinky-sized hole the ER cut into the abscess was a gross underestimate for the nearly hand-sized abscess.

This might be a little graphic, so unless you're Uncle Kevin, you may not want to read. When you're dealing with an abscess, you can't pussy-foot around it. You have to cut a big enough incision to allow aallllll the puss to get out. In order to ensure that, once you incise with a scalpel, you poke around inside the wound with a blunt probe to find out how big it is and where its borders are. When we had examined the patient this morning, we saw a teeny hole surrounded by purple skin. She still had a fever after nearly half a day of IV antibiotics, so it didn't surprise us to find another hard, red, hot area two inches away from the ER's incision. She needed surgical drainage.

Once in the OR, we cooed and talked to her to keep her calm until the anesthesia took effect. Then they went to work. The surgeon found a large two-inch tract extending from the original abscess incision to a large pus pocket on her thigh. He found another smaller tract extending about one inch below. He made an incision in each of the new pockets, picked up an instrument that looked a lot like a turkey baster, and started squirting saline into the abscess one incision at a time. It was crazy to see the stuff coming out of the other incisions in her legs. I was grateful I still can't smell anything because necrotic fat and blood just gushed out of her wounds. Blech.

When we went out to talk to her parents, something was weird. I thought it was just a cultural difference, young separated parents and all, but then I put my finger on it. Dad was high. Not just high, but HI-IIIIGH. Now, I didn't formally test him or anything, but I would bet my student loans that was what was going on. We're taught to be observant. Oh yeah, and then the next day we heard that there was a shouting match over not "doing drug deals while your child is in the hospital. "

I see a lot of young, unprepared parents in this town. I don't have the prejudice that young and single= terrible parent. Buuuut when I know in two days I'm going to release a baby who gets 10 day stretches of quality time with a dad who can't seem stay clean for a single day, it takes a little longer to fall asleep that night. The weirdest part about it is that I can't find a fault in his chain of action for the baby. I read the reports and took histories. I think he did everything he could. I think he did everything I would have (if I weren't a hypochondriac medical student). Surely he can't be competent enough to take care of this kid. But if anything, it was a missed diagnosis at an urgent care center several days earlier that led to the abscess' impressive size. If you looked past the jumpiness and twitchiness and pressured speech you could see fear in his eyes. Now, I don't know if it was pure drug-induced paranoia, but I'd like to think it was genuine concern for his kid. Maybe that's why he got high; he couldn't take the stress.

Either way, I didn't want to give the kid back, but I had no reason not to. I just wonder what kind of life is she going to have. At what age is she first going to realize what Daddy does?

All the doctors involved in the case (including me) asked the same question at first: "How could the parents let it get this big?" Things get a lot squirmier when you can't blame something on the easy target of the addict dad or young ignorant mom. It wasn't their fault, and the fact that we all stubbornly assumed it was is keeping me up another night.

Monday, October 20, 2008

Did you just spit in my mouth?

A six-month old spit in my mouth this morning.

I was leaning over her innocently performing my well-child exam as she started blowing raspberries. "Oh how cute!" I thought, "It's a pre-speech skill!" Then she straight up spit in my mouth. Why was my mouth open? BECAUSE I'M STILL SICK AND MOUTH-BREATHING FROM THE LAST KID WHO PICKED HER NOSE AND PUT IT MY MOUTH WHEN I WAS DISTRACTED.

At least I know she's been vaccinated.

Later in the afternoon, after I had thoroughly rinsed my mouth, I walked in another room to see an orange baby. Yep, I checked twice and put in my eye drops. She was orange. Everywhere. Except for her eyes. That's the clue to what was going on with her. A jaundiced baby can turn orangey-yellow, but her eyes will be jaundiced too. This baby was nine months old, and loooooved her sweet potatoes, carrots, mac and cheese, basically any orange food. I guess sometimes you really are what you eat.

On that note, just so you know Mom, I bypassed the fresh-made onion rings the cafeteria ladies were shamelessly hawking tonight in favor of some tomatoes...balanced out by a nice green salad. I don't really remember the color wheel details, but I think if I eat both of those I should turn out a nice browny-tan color.

And I don't care how scary it makes me look, tomorrow I'm wearing a dang surgical mask.

Thursday, October 16, 2008

Shut your mouth!


I hope that as I go on in my medical career, I will learn to control my mouth. In the meantime, here are a few choice quotes from the clinic:

"Have you ever wondered if that's a third nipple?"

"She looks like you, but with more hair."

"Are you having sex talks with your child yet?"
The 10 year old boy: "I already know, don't do it when you're married!"

"My, your daughter certainly has sturdy legs"

"Ix-nay on the nipple thing when the real doctor comes in--that woman
is in charge of my grade."

"HOHHH! That is disgusting"

"That reflex was totally fake."

"Are you seriously whining about the ear exam? Want some tissues and
a sticker?" (That was to a 15 year old boy with quite the 'tude)

"I'm sure that nostril flaring trick gets all the ladies."

"Sure I've stitched before. Not on people, but they say pig skin
teaches the same thing."

Oh no Oh NO CRAP he peed all over me!"

"Well of course you gained weight when you went off your diet."

Tuesday, October 14, 2008

Vaccinations-LOOK OUT!


Today in clinic I had a particularly precious baby in for a well child check. She's six months old; so she's not afraid of me and will even giggle and interact--a big lift considering two kids screamed as soon as I walked in the room that morning. Anyway, she had blue eyes, pale skin and chubby chubby cheeks--if the Marshmallow Man had a baby girl, she would look like this kid.

Well child checks are when we typically give the 2, 4, 6, 12, and 15 or 18 month immunizations (they poor little guys get another round when they go into school too). Something I didn't know before this rotation is how many parents choose not to immunize their children.

It's never a good idea to call a parent crazy or ignorant to their face. But what does one do when someone tell me that they don't want to immunize their child because vaccinations are a "government conspiracy trying to brainwash parents" ? I'll tell you what I do. The first time I waited a few seconds for the parent to laugh so that I could too. When that didn't happen (yikes), I quickly dropped all emotion from my face. Blank slate. I just try to totally empty my mind for as long as it takes and sit there, glassy eyed, until I can continue like a professional. It's a trick I have worked hard to perfect. One day on Family Medicine a lady was telling me all about her guava juice and cayenne pepper "detoxifying cleanse" (and didn't mention the 1/2 pack she smoked a day) and I had to hold the face so long I felt a little drool coming out of the corner of my mouth.

Only when I am outside of the room do I let myself think: "Yeah, it's a conspiracy. Against HORRIBLY DEVSTATING CHILDHOOD DISEASE!" But sure lady, I think it's totally possible that the CDC, American Academy of Pediatrics, FDA, and American Academy of Family Physicians are all sitting together in a bunker giggling about how they got us to poke needles in children for the yell of it.

Here are some reasons I've heard for why parent's don't vaccinate their children:
--"We are waiting for her immune system to develop a little more."
Vaccines work by stimulating a child's natural immunity so that if it ever encounters the real thing, it is already prepared to fight. With the exception of MMR (measles, mumps, rubella) and Varicella Zoster Virus (chicken pox) which are live attenuated (weakened), vaccines are dead dead dead, either killed like the polio vaccine (IPV and the flu shot), toxoid like diptheria and tetanus, or made from a compenent like Hib, Hep A and B, and pneumococcal. You give MMR and VZV at one year of age when the little ones are stronger anyway.

--"I've done a lot of research, and we are worried about the link to autism"
Here's a little more research for you to read:
CDC's position on thimerosal and autism
American Academy of Pediatrics latest study on purported link to autism

--"I don't want my child to cry from shots"
Hmmmm....I'm sure they'll cry a lot more when they get MEASLES. Though I totally support your parenting style of making decisions about his health and well-being based on whether he cries or not.

Parents have the right to choose whether or not they immunize their child. I support those who have put a lot of effort into researching; I truly believe they are trying to make the right decision for their child. That is how I can discuss the options with the parents rather than sit silently and alienate them. I simply come to a different conclusion when I read the available evidence and couple it with the fact that children suffer and sometimes die from these diseases.

And why would doctors spend years of their lives and hundreds of thousands of dollars they don't have to hurt children? We want what we honestly believe is the best thing for your child.

Part of the success on vaccines depends on herd immunity. We are starting to see outbreaks of measles where an unvaccinated child was the original vector, but children whose immunizations didn't produce enough response, or children who were not able to be immunized, were sickened. The more parents do not vaccinate their own children, the higher the disease burden and the more other children will also be affected. This does not seem right.

We as a nation are fortunate in that we largely do not remember the suffering caused by vaccine-preventable diseases. Instead of seeing the morbidity and mortality of measles we can focus on the possible links, the shadowy conspiracy theories with the vaccines. In the end, I think what it will take is children dying from diseases we had previously nearly irradicated. Then the reality of these illnesses will shock parents into vaccinating their children.

Monday, October 13, 2008

Children Make Me Sick

Literally. This morning during clinic I felt my throat start to tingle, then tickle, then...ooooohhhhh so sore. Being stubborn and a little stupid at times, I ignored it and kept going. As the day went on, I felt progressively crappier. Here's a rundown:

9:30 am: Hmph. My throat hurts a little. Wonder if my mouth is dry or it's allergies. Though usually those get better as the day goes on...
10:30 am: Good gravy my neck is achy. I guess I slept on it wrong. Oh there's a 2 year old to exam; better keep moving,
11:30 am: Head hurts. Must keep going. Can't have my preceptor (doctor that determines my grade) thinking I'm lazy. Why do I have ear and jaw pain? Ear infections aren't contagious are they?
11:40 am: Crap, did she see me put my head down in her office? Quick, while she's busy with an adult I'll just check xkcd.com for a few funny comics to wake me up.
12:00 pm: Just. keep. moving. Oh the drug rep brought peppermint patties. I believe those are very therapeutic for sore throats. I think a good dose is 5 patties...
1:00 pm: Broke down to ask if there was any ibuprofen in the office. Ended up on the wrong end of a strep swab. Now is not the time to show off my impressive gag reflex. Hope I've always been nice to this particular nurse.
1:05 pm: Hmph. I guess not.
1:20 pm: "Allison, go home if you don't feel good." But wait! There's a kid with possible appendicitis. Dang it I've never seen that.
2:00 pm: I can't take it anymore.
3:00pm: ZZZZZzzzzzzzz
5:00 pm: Oh licks and giggles even my calves hurt. I hate children.


"Yes, that's it, breathe all over me dear."

Yes, as my doctor so helpfully mentioned during the day, I carefully wash my hands before and after each visit. But when you spend your days a stethoscope away from snotting spewing little darlings, eventually your immune system says, "What the crap you masochist?" I lasted longer than my roommate. I'm in my third week; he succumbed during week 2.

Something interesting: My ear/jaw pain (you can get both b/c they use the same nerve) is most likely not from an infected middle ear (aka acute otitis media), but from fluid pressure. The cycle usually starts from something (a virus? allergies?) inflaming your throat. This can close off the eustachian tubes which normally drain your ears. Fluid builds up and bothers the crap out of you. Sometimes it gets infected--then it's AOM. I took an antihistamine and an anti-inflammatory (decongestants work too) which presumably decreased the swelling in my throat. My ear could drain, and three hours later I felt like I could hold my head up straight again.

Saturday, October 11, 2008

You Can't Fix Stupid

Yesterday we admitted a 2 month old whose mother said turned purple
this morning. From the sound of the history, she had an apneic
episode, possibly a ALTE--acute life-threatening event. It used to be
called Near-miss SIDS, but ALTE is the term used now.

While I was taking the history I asked if there were any smokers in
the house. "Yes", the mother said. "How many?" "Four". Four
smokers around a precious two month old baby. A two month old who
turned purple yesterday from not breathing and might have died.

This morning when I went to round on her in the hospital the nurse's
report said the mom had screamed every time the baby "stopped
breathing". Babies' breathing can pause for several seconds, that is
perfectly normal. From the nurse's report, she was breathing normally and her oxygen saturation remained fine the whole times. Unfortunately, mom was already on edge and took the opportunity to scream obscenities at the nurses while yelling into her
cell phone that "They are not doing anything!! She's dying!!"

Things had calmed down by the time we went to the room. We explained
that her tests were normal so far, and that what may have happened was
that she had a viral illness and the FOUR SMOKERS around her probably
filled her little lungs up and irritated them so much that she
couldn't breathe. But in a tactful way of course. Actually, my
doctor handled that part because she has more tact in the face of
stupidity than I do. She said it takes years of practice. When we
explained that any smoke around a baby increases her risk of SIDS and
for the health of the baby they should stop, her reply was, "Well,
it's not our house so I don't feel comfortable telling other people
what to do."

I can understand that is a precarious situation. So we suggested that
people leave the house when they smoke. They are family after all,
and surely care about the baby's life. "Well, the thing is several of
them are disabled and can't move to go outside every time they have to
smoke." Ok. I have seen plenty of people who disregard their own
health, like the 52 year-old whose oxygen tube was brown from smoking
while she was on it. So the fact that people whose bad habits may
well have disabled them continuing to smoke doesn't a. Surprise me or
b. Make me pass judgement. I'm not in their situation and it is
their body. But this is a baby, and they are putting her health and
possible her life in danger. It is baffling to me that someone
couldn't put down a cigarette for such a sweet helpless being.

On our way out of the hospital we passed the mom. She was going
outside to smoke. I wanted to tackle her and stuff cigarettes in her mouth until she
saw the error of her ways! Buuuut, aside from being unprofessional,
her size, stubborness, and facial hair made me think it wasn't a fight
I was going to win. All I can do is hope the next time I see the baby, it's for a Well Child Check, and not for pneumonia.

Thursday, October 9, 2008

Torture Me Elmo

I torture children. At least, that's what you would think if you spent some time in my clinic.

Kids are usually pretty cooperative until around 9 months. Then stranger anxiety starts to kick in. I don't blame them. They shouldn't like me. I poke and prod and check their business in front of everyone in the room. Then I unleash the nurses to give s-h-o-t-s (you have to spell a lot when you're in pediatrics). I'm pretty much the gateway to evil in a kid's world. And I don't even give suckers.

I let them play with my stethoscope. I try to show them my otoscope won't hurt by putting their little fingers on the light so they could see it glow. I try to let them poke around so they give me the same courtesy. I even let a 15 month old put his finger up my nose. Not really let so much as "was distracted while the surprisingly quick little hand popped up".

I had a perfectly precious little guy in my clinic that screamed bloody murder every time I touched him. And only when I touched him. It was bizarre. I could be in the same position, right up in his face, stethoscope outstretched, but as soon as I actually touched it to his chest, WWWAAAAAAAHHHHH!! So I'd take the stethoscope off but otherwise didn't move a muscle and immediately--silence. Touch the stethoscope-SCREAM! Take it off--sucking his thumb. I tried it several times to make sure I wasn't making it up. His mom and I had a good laugh while I did it, but secretly I wonder if she didn't just bring a slightly larger Asian version of Tickle Me Elmo. Or Torture Me Elmo.

I think I'm slowly getting better at the ninja-peek. Or when all else fails, Mom or Dad holds the goober's arms and head for dear life, and I say a little prayer of thanks that I don't have to go home with the screamer.

But I really do love the cuties. :-)

Tuesday, October 7, 2008

Circumcision touches a nerve

It shouldn't have surprised me that people want to talk about circumcision. But I am surprised that people are reading this blog who aren't related to me (and therefore, under pressure to read it). Here are some more thoughts about circumcision I learned from my pediatrician and research:

1. Why is female circumcision "genital mutilation" but male circumcision is not only culturally acceptable but something that parents feel like they have to do to make their kids normal?

2. Out of the English-speaking countries that used to practice circumcision (US, England, Canada, Australia and New Zealand), the US is the only one who still circumcises the majority of its babies.

3. Male circumcision in the US was advocated in Victorian times as a cure for child masturbation. Yeah, from what I've heard that works really well.

4. Here's a little quote from Dr. John Harvey Kellog (same guy whose corn flakes I now look at a little differently)

"A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement. "

(John Harvey Kellogg, M.D., "Treatment for Self-Abuse and its Effects," Plain Fact for Old and Young. Burlington, Iowa: F. Segner & Co. (1888). P. 295

Enjoy your breakfast. Did anyone else just about mess themselves when they read about the carbolic acid?

Soon I hope to tackle the thoughts I have about Medicaid and Medicare, but that's such a huge topic I'm sure it will turn into a series.

Saturday, October 4, 2008

Moobs!

I saw a baby lactate yesterday.

No, really. It happens. When both baby boys and baby girls are hanging out inside mommy, they are exposed to hormones galore. These hormones cause them to develop little breast buds: actual breast tissue fat pads. There is a difference between a fat chest and man boobs--moobs if you will. The real term, just so I use the knowledge I'm paying dearly for, is gynecomastia from "gyn"-woman and "mastos"-breasts. To truly call it breast, there has to be a palpable little bud of glandular fat right underneath the nipple. Fat is only fat, unless you have glandular proliferation.

Gynecomastia. Image courtesy of Robert Paulson. Actually, this is him in the flesh. Since this is a dude, this isn't obscene, right? What do you think Mom?

So what causes moobs in adults? Well, when the processes in your body that are designed to create or break down hormones (mainly estrogen and testosterone) are altered, it alters what God intended. Either estrogen increases or testosterone decreases. Either way, estrogen wins and Viola, moobs. Some examples of causes: Liver disease (the liver is supposed to clear estrogen in a healthy person), kidney disease, medications such as spironolactone (for high blood pressure) and several HIV treatments. That's only a sample! Technically, obesity can cause gynecomastia because fat actually creates one of the forms of estrogen. Crazy.

Anyway, when my attending and I were examing this new baby, we found breast buds. Eager to teach me, she said, "And sometimes, you can actually..." and pressed on the baby's buds. Wouldn't you know, a little serous fluid came out! (In another ultra-professional moment, my reaction was "Aack!")

Here's an emedicine article for further reading if you're interested.

Wednesday, October 1, 2008

Circumcision--Let's cut right down to it.



I saw a circumcision the other day. It was traumatizing.

First of all, the longer you wait, the bigger the foreskin and the bigger the blood vessels. Not good. This baby was a week, a few days older than my doctor preferred, but the problem is that a hospital circ would cost $1,000 (an estimate from my doc for my area) but in the family doc's office it's only $150. Medicaid doesn't pay for circumcision by the way, so no one on Medicaid wants to get it done in the hospital. Usually it's at least two days before the baby gets to the clinic.

For the not so squeamish, I'll give you a rundown. The parents go out of the room because they don't want to see what they've just signed their newborn up for. Next we strap the poor little unsuspecting goober to a white baby-shaped board. Naked. Screaming ensues, and that's all before we get out the Gomco (a metal clamp contraption with a hole in the middle for you-know-what).

This particular doctor didn't use general anesthesia because "there's no evidence that it does more good than harm. I'm sure that clamp hurts like hell. In my readings since, I've found that there are options for anesthesia, but honestly, after seeing that all I can think about it is "AAAAAAAaaaaHHHHHHhhhhh!" By the way, the parents are nowhere to be found at this point. Lucky jerks.

I hope that if I have a little boy, I have the guts not to circumcise him. In the US, 50% of boys aren't circ'd anymore (down from 80% in the 80's). The American Academy of Pediatrics doesn't recommend for or against it. Neither does American Academy of Family Physicians. I'm a little afraid of him looking weird in the locker room, but for peter's sake that procedure cuts off the most sensitive part with only a 1% absolute risk reduction for UTI and 0.1% reduction for penile cancer. Yes, there may be a reduction in STD transmission, but aren't we all supposed to be using condoms and good hygiene anyway?

I'll try to post a picture. But in the meantime I just hope I'm not asked to step in. I'm not ready to be entrusted with a little dude's future pride and joy (I assume he could care less right now. I am female however.)