Tuesday, November 25, 2008
Yesterday morning I started Neurology. I'm only in it for two weeks, so I have to make it count. Unfortunately, Thanksgiving is in two days and then it's Christmas and then it's time for my annual SNOWBOARDING TRIP!!
So I'm having a little trouble concentrating.
Neurology is very interesting. It is so logical: lesion here? Oh, that will probably affect here, here, and here. It's so well mapped out--which, by the way, we mostly learned by watching what people with brain injuries acted like, then peeked into their brains once they died to see where the lesions were.
Take Phineas Gage. He was a mild-mannered church going railroad worker when one day an unfortunate explosion put an iron rod through his forehead. He calmly walked himself over to the doctor and had it removed. Miracle, right? Well, yeah, but that's not all. The formerly polite quiet-living man turned into a drinking, gambling, potty-mouthed man who ended dying early from impure-living anyway.
From poor Phineas we learned the role of the frontal lobes in forethought, planning, personality, and impulse control. By the way, they're not fully developed until you're about 25, which I try to keep in mind when I deal with teenagers.
Read more at Encyclopedia (it's also where the pic is from)
Tuesday, November 18, 2008
Thank God my (male) doctor was not in there with me when I had to do that. The nurse nearly peed herself laughing.
Friday, November 14, 2008
Usually I'm pretty cold-hearted about taking away binkies, giving shots and the other various little tortures we put kids through. I try to make the kid comfortable, and don't prolongue the torture, but I have to be pragmatic. There's no way to reason with a 2 year old about giving shots. 5 year olds don't understand logic. One 11 year old boy was the biggest baby I had ever heard about getting one little shot--he had to have two adults hold him down. Sometimes you're the adult and you just do what is best for the kid no matter how much they scream.
A young girl came in for a well check and I started to read her chart to prepare before I went into the room. Her ear was bothering her and we were probably going to have to scrape out a tube with the little metal currette. It's not usually a painful procedure (the tube is already out of the eardrum and sitting in the ear canal), but sometimes when you get the cerumen (wax) out, the underneath of it is a little irritated. A little irritated was an understatement for this kid. I had the job of holding her arms down while she begged us not to take it out. She was terrified, and what was in her chart made me feel absolutely horrible about doing it.
She had been sexually abused mulitple times by a teenager in her home. When I read through the chart my heart sank, then I just felt numb and overwhelmed. Such a bad situation.
What do you do when both abuser and victim are your children? Do you still love your child? Do you still feel like he is your child? I wondered what kind of a mother can let her child back in the house knowing he hurt the other children, but can you turn him out of your house when he has nowhere to go? Does love switch to hate easily, or do you waver back and forth feeling terrible and guilty on each side? Usually an abuser has been a victim himself at some point--did someone hurt him first? Does that make it easier to help him, or do you just feel helpless in breaking the cycle?
Sometimes we have to do things that cause kids pain. I knew it was for her own good but contributing to her fear and pain made me want to throw up.
Wednesday, November 12, 2008
Doing a physical exam on the little guys can be tough. They usually don't understand directions, and when they do they feel no obligation whatsoever to humor you (at least the 2-3 year olds). Sometimes I use their desire to imitate and do whatever it is I want them to do. I'd say 40% of the time it works all the time. It usually makes them laugh at least, but there are hazards. Demonstrating "AAaaahhhh!" is how that 6 month-old spit in my mouth last month.
Looking into their little mouths is particularly tricky. If they are fond of the binky, I tickle their bottom lip with it--I know, I'm such a tease. They either open their mouths or start licking their tongues in and out. I either see inside or get a good laugh out of how funny they look. Another favorite trick is to let them hold the otoscope. Within 5 seconds they open really wide so they can stick it in their mouths. Lastly, if they are already screaming at something else I've done to them, that's the best view. I don't like to use a tongue depressor. Honestly, if the kid is already irritable I usually don't bother trying to look. The "Real Doctor" is going to look at them anyway. No need to doubly torture them.
One kid today just looked different. He was only 11 months old, but had an odd red rash all over his body. I had never seen anything like it. Usually when that happens, I just say, "Well, I think it might be this, but Dr. So-and-so has had much more experience looking at these things" and hightail it out. After I've seen it, if I don't know immediately I'm not going to, so I get out asap and go try to google something like it before I have to present the patient and give my hypotheses. Google images really helps me save face with my preceptors.
This time though, I sucked it up and got out the tongue depressor. There it was--a red puss-pocket throat. Even though strep is rare in kids younger than 2, I asked the nurse to swab him. Sure enough, it was strep. I was happy we found it and could treat him, but it sure made me regret not waiting for the "Real Doctor"--when I used the tongue depressor the kid wet coughed spittle droplets all over me. I swear if my throat tickles tomorrow I'm going on antibiotics.
Tuesday, November 11, 2008
Halloween is a great day to be in a Peds clinic. My family has an enormous collection of costumes. One day I found this child's dino costume and discovered I could squeeze myself into it (my enormous head is the only part that gave me trouble). I've been waiting for an occasion to wear it--and what a perfect time! I sure as heck wouldn't have gotten away with this outfit in Surgery.
The 1-2 year old crowd weren't too sure of me. They already have a good healthy fear of strangers, and one dressed as a dinosaur with an otoscope certainly didn't endear herself to them. I tried to talk in a dino voice, but I don't really know what that would sound like so it came out as a weird, doofus Barney-like voice. I only tried it once. I let the little kids pet me; that seemed to warm them over a little bit. The costume was very soft, but I think one of the 3 year olds definitely tried to cop a feel.
The teenagers were mildly amused, but of course not overly excited because that would be showing too much interest in a relative grown-up. The costume was a HUGE hit with the 4-7 year olds. My last patient of the day, a 6 year old boy, nearly jumped off the table when I walked in. "She's a DINOSAUR!!!!!"
That night I ignored the fact that the armholes really didn't fit as well as I'd thought and pulled an enormous lacy circa 1980 wedding dress over the top for a costume party. Get it? I was Bridezilla!
Haahahaha. Seriously, that is way funnier that "Slut du joir".
The fact that the back of the dress didn't zip all the way up past the "athletic ribcage" that the David's Bridal saleslady so kindly pointed out last year only made the costume better--it meant my purple shiny spikes and little tail wagged out the back. It's almost reason enough to go into Pediatrics.
Monday, November 10, 2008
When I walked in the room I saw a 254 lb. 13 year-old girl. As callous as this sounds, I thought--"Well, there's your knee pain."
This girl was pleasant, polite, and honestly much nicer to work with than most of the other teenagers. She's just on the fast track to an early death. I sat there, trying not to reveal my thoughts, mind blown by the magnitude of the problem and all the pain and suffering she is setting herself up for. I asked if my doctor would mind if I stayed and talked to her after the visit, maybe counseling her a little on how her knee pain is probably related to her weight. "Go ahead" he said, "but you might want to know we've had two-hour counseling sessions, enrolled in Weight Watchers Youth, arranged for a dietician, and nothing has worked yet."
He then said if I wanted to I could take it on as a project and schedule her as my only patient to see one afternoon and just talk to her. I think I'm going to do it, but not because I have any hope of changing anything. I am hoping to get a little personal perspective from her. I know my side of the situation; in order to ever be of any help I need to understand hers.
Friday, November 7, 2008
They are so roly-poly and cute with their double chins and baby-boobs and round bellies. It cracked me up when this one baby's legs were so big I had to push back the fat to test his reflexes. And even though I hated it when great-Aunt Marjorie would do it, I always want to give their chubby wittle cheeks a pinch.
It's all fun and peekaboo until I see that Mom and/or Dad are overweight. How are you supposed to know when to start worrying about weight in a kid? I asked my preceptor and he said once they've been walking for six months, if they are still overweight (comparing weight %-ile to height), then he starts to address it.
Babies are born with a good sense of hunger. They will tell you when they are hungry (well, scream) and naturally stop eating when they are full. It's the grownups that train it out of them. When they are little drool-pots slobbering on themselves, sometimes parents push food on them because "it's been four hours; time to eat". Then as they grow parents introduce them to their own bad habits by giving them juice (one doctor calls it "Nature's Soda) which is generally crap, soda, and basically fat and sugar loaded food. Then they wonder why the kid won't eat vegetables. Here's a secret-no kid is going to starve herself. Don't try one spoon of carrots and then switch to ice cream "to make sure she gets her calories".
While we were in the clinic for a 15 month well check, one mom's "friend" (I don't really ask usually) opened her 20oz bottle of Dr. Pepper because the kid was mad and let her sip it so she would stop. I nearly croaked!
A week ago I walked in to a well child check and saw the fattest baby I've ever seen. He was 17 months old and weighed 37 lbs. When I held his hands, they squished like the Pillsbury Doughboy's. That wasn't even the worst part for this kid. It seems that Mom and Dad don't ever want to cut his hair, but Grandma babysits and wanted it to look nice--the poor kid spends his days ambling around with his hair in a slicked back pseudo-mullet.
Grandma was clearly concerned with his weight. She said she thought his parents were feeding him things like Hamburger Helper and Velveeta cheese because they couldn't afford better food. I don't believe it. I think people get sucked into that sort of food because they don't know how to cook, they don't follow sale prices, and they don't ever think outside the box (literally in this case). The parents live off of processed crap, and they force-feed it to their kids. You can buy lean hamburger and noodles and make a one-time spice investment and have the same meal but with less salt and less fat. When I was in AmeriCorps I lived off of food stamps and never once ate Hamburger Helper. I could still shop the perimeter of the grocery store and make good meals. Granted, I don't really remember what I ate, but I lost weight so it was probably good for me.
The reason I get so worked up is because these babies come back to us later as overweight children. They get picked on, they don't exercise as much, and they are even starting to complain about knee pain and back pain. One sixteen year old the other day was developing insulin resistance--enough that her blood sugar was starting to show it. By then the habits are ingrained and they are on their way to be obese adults.
Parents act like it is inevitable. They call it "genetic" because they are overweight. They don't act like parents and take away the soda or the candy bars (um, my mom would never have let me eat a regular sized candy bar, and sodas were a once a week occasion--and diet then!). It's not inevitable. It's calories and exercise. And it's something you need to do.
I could go on for a while, but I need to go talk to a kid about her BMI right now.
Wednesday, November 5, 2008
My current attending likes to quiz me in front of patients in a "guess what I'm thinking" style. It's oh so fun. Don't get me wrong, he's a very detailed and enthustiastic teacher. I just might lose my mind before it's over.
Usually I can tolerate it, even appreciate it, but lately I've been getting less sleep due to studying (and of course, the election), so as we say during our behavioral talks, I have fewer tools in my toolbox to deal with my emotions. The last straw was this morning when I had to do an on the spot history and physical, complete with presentations of findings, in front of the patient and her dad, then answer a series of questions which devolved into mathematical parlor tricks to calculate her appropriate dose of amoxicillin (in liquid form because that's more difficult).
A snippet of the more ridiculous part of the conversation:
What do you think is going on with this patient? Strep throat or a virus
How would you treat it? I'll assume it's strep right now until we get the cultures, and treat it with amoxicillin
What is the dosing schedule? Twice daily for 10 days
What is the dosing amount for children? Umm...400 mg/kg/day? (Actually 40mg/kg/day)
She weighs 22 kg. How much would you give her? What is this, a math test? Ok,ok..880mg/day
Would she take that at one time? No, it's bid dosing, so it's actually 440mg/time
The liquid dosing is 250mg/5ml. How much liquid does she need? You have to be kidding me.
At this point I was starting to feel trapped in the tiny room with all eyes on me, so I just guessed 7.5 ml. I figured I was probably close (my mom is a math whiz after all).
Actually, that would only give her 775 mg. Wouldn't you say 8.5 ml is a better dose? Sure. (Why is he doing this to me? Crap I was so close!)
At this point he turned and typed the medicine into his computer, where the medical program took the patient's weight and liquid suspension and calculated the correct dose.
It's difficult to explain how nerve-wracking this is. Imagine every two months you are given a new area of expertise to learn at work. Then each day while you are attempting to learn you are forced to stand for 20 minutes at a time(no one offers a medical student a chair) 25-30 times a day in front of your new boss--who determines your evaluations and possibly future--and a few strangers, answering question after impossible question. It's enough to give a reasonably sane woman a nervy spaz.
It doesn't matter if you get 5 questions right, when you miss that 6th question you get a sympathetic/surprised look (Oh, you didn't know that? You really should), and then the next day you present on "Denny's Crease". Denny's Crease was another question today--according to him that's the name for the crease kids get in their nose from wiping it with allergies. When he pressed me about that (Just saying "crease from allergies" was not specific enough) I finally broke down and said, "How would I ever know that?" I came home and googled it; you know what I found it to be called? "Allergic Crease".
Why do doctors do that? Guess what? I could do the same thing to you with Saved By the Bell references. And I think it would accomplish about as much as those math questions.
After a day like today I would unwind with a beer...but I'm on call tonight and at any moment the pager could go off for another round.