Resilient Doc’s Blog

So yes, I know, it has been a while, but sometimes you have to wait for just the right case. Oh sure, I have had lots of interesting cases since I have been on the floor, but to be perfectally honest, they have all been pretty sad, or just made me angery. I wanted to wait for something a little lighter to write about, well, here it is.

I was on call last night, and it was one of those nights when you knew you were not going to get any sleep. Why? Because all the crazy shit happens after midnight. I mean, I had been at work since 6am Sunday morning and it was quiet as a church mouse..but as soon as the sun goes down, that’s when kids blood sugars decide to sky rocket, lines decide to get plugged up, ect.

Well, I had just laid back down at 3am when my pager goes off. It is a text page saying that there was a consult in the ED. I go ask the nurses about it because my senior was no where to be found. They tell me that the kid has got a case of uncontrollable laughter.  Odd I think, but I make my way down to the ED to meet this patient.

As I walk in, there was this little seven year old boy who could not stop laughing. He had been laughing like that for the past two days. Just non stop. It was like one of those Batman episodes where the Joker was the villain of the day, and he had some how poisoned this child with his laughing gas. So, I get the story. Without going into too much detail, this is a little boy who has cerebral palsy and an underlying seizure disorder. He had been in his normal state of health until about ten days ago when he got the flu. He was given the flu shot, and a couple of days later the flu medication.

Here is the “funny” thing about the flu medication. First, it lowers seizure thresholds and has seizures and delerium as a side affect. Anywho, after getting the story from the parents…I leave the room puzzled because I have absolutely no idea what to do for this patient. All his labs had come back normal. No sign of infection, He was eating, pooping, and peeing alright. His vitals signs were normal, he just could not stop laughing.  So, I gave him some ativan to calm him down, and well, after the shot, he was fine. We ended up admitting him for observation, and he went home the same time I did later today. The nurses were a little dissapointed that he had stopped laughing by the time he came to the floor. They were very curious. So was I actually. I mean, this might be the oddest case I have had. Uncontrollable Laughter. I did some reading. For those of you at home who are interested…look up Gelastic Seizures. I probably will never see another case again.

Also, even if I think it might have been a waste of money for that family who also had two little kids at home, to stay the eight hours in the hospital. I think it was a good thing that we admitted him. Observation admissions cost the family less money than real ones.

Do you remember what it was like to be eight years old? Try. I was in the 3^rd grade at brand new school. I was the weird kid cause I was from AFRICA, but I still had a good number of friends. I got in trouble in class for talking too much and having “sticky” fingers, but other than that was a pretty good kid. I mean, there were times that I got sad like most kids did, but in general I was pretty happy. I always felt safe at home, and when the thunderstorms scared me and woke me up, I knew that I could always go upstairs and wake one of my parents up. Nothing really too major. I assume that most of your eight year olds were pretty similar. Generally happy, and felt safe.

Well during my behavioral pediatric rotation, I met two eight year olds that had undergone completely different experiences.

The first was an eight year old boy who came into one of the clinics that I was working with because he was depressed. Before meeting the boy, the biased thought of “yeah right” had popped into my head. I had created this preconceived notion of what his parents were going to be like. I was totally wrong. This little eight year old boy was in the process of recovering from depression. At the age of six years old, he had already tried to kill himself by “getting all of the blood out of his body”.  He didn’t have any friends, he didn’t know how to talk to anyone, and he was totally withdrawn from his family. He is the oldest boy and has a two year old little sister. What about the parents you may wonder? Well, both parents are as sweet as they could be. Attentive, creative, educated parents who really had no idea what happened to their son. He had always been a quiet child, but had been pretty happy and was developing well. Then around the age of 5, his symptoms really began to become more obvious. Did something dramatic happen to him at the age of five? Nope. It turns out that the symptoms may have been there, but it is really hard to diagnose depression in a child. To be honest, I didn’t even know that you COULD be depressed as a child. I had always thought, and maybe even learned some place along my education that the earliest onset of depression was at age 15.

So, what happened to this child? Why was he depressed? I asked my attending after our session with him was over, and she said it was most likely an inherited imbalance of serotonin. This didn’t make sense to me because depression didn’t run in the family. I did some research and all I could find were articles that taught primary doctors how to screen for major depressive disorder in 7-18 year old. I clearly have some more reading to do. The point is, that kids this young can not only be depressed but also suicidal.

What did we do for him? Play therapy. This has been the  11^th session for this family, and I just happened to be there for the break through.  We were throwing around a ball that had emotions written on it, and wherever your right thumb landed, you had to say something that caused you to have that emotion.  Well, at one point, my finger landed on scared. It so happens that I am still afraid of storms, in particular lightening. So, I said this, and the kid actually smiled in empathy. This was a big deal. His mom said this was the first time she had seen her son smile in months. Things went progressively well after that. It was probably the best 30 minute clinic session I have had so far. I have to go to work now, so stay tuned for part two.

Ok, inflammatory subject heading aside, let me first say that in general, I believe in behavioral disorders. I do believe, and have seen children with Attention Deficit Hyperactive Disorder, Autism, and most of the rest of them. I do believe that these children need to be identified early so that they can get the help they need. That said, there is a gross over-diagnosis of these types of disorders, and some kids are given these “diagnoses” and are then stuck with these labels the rest of their lives. I am currently in my behavioral and development rotation right now, and have been witness to these gross misdiagnoses.

Case Number 1: Nine year old girl who has a fraternal twin brother who is autistic, and who was diagnosed at the age of 4.  The girl’s parents brought her to the clinic because for the past year, the child has started to develop some strange stereotypical movements, facial ticks, and has strange interests. These strange interests include a fascination with microscopes. Per mother all she wants to do is make slides, and then look the things under a microscope. She loves Animal planet and talks about the shows on that channel all the time. Per mom, she doesn’t have any friends. She talks insensibly and continuously to anyone and everyone. Even the dog.  The stereotypical movements include wringing her hands when she is nervous, and flapping her arms at random time. Facial ticks include facial grimaces and perioral tongue movements at random times. She is also having educational problems at school starting this academic year. Though the other “strange” behavior have been creeping up for the past year or so, these “symptoms” seemed to have really escalated in the past couple of months. Now, this is all per mom’s report. The child herself is a pleasant talkative girl. Who does in fact like to talk. She has a great social intelligence and can tell us who are friends at school, and who are just acquaintances. We worked with the child for an hour putting her through some social, behavioral and intelligence tests in which the girl is right at average for all. Now, as for the girl’s “ticks”. She likes to stick her tongue out and make funny faces. If one were to ignore these faces that she makes, she increases them till you have to say something. When she is concentrating on a task, these facial ticks do not occur. When you ask her to stop whatever she is doing with her tongue and mouth, and face, she does. When you ask her why she does these, she says its fun. We asked her about school. She says she has two good friends, but a lot of kids pick on her because she sticks up for her autistic brother…oh, who HAPPENS to be in the same CLASSROOM as she is.

So, let me cut this short. You get the picture. This is mildly weird kid is tired of her brother getting all the attention all the time, and wants a little bit of the action as well. It is hard for her to concentrate at school because she is taking care of her brother. Her mother, who already has one autistic child wants a diagnosis for the girl also. And what do we do? WE GIVE HER ONE! I could not believe my ears as the diagnostic team (which includes a Developmental Pediatrician, a child psychologist, a language specialists, and someone else I can’t remember who she was), basically talk each other into giving this kid three bogus diagnoses. I mean, are you serious? One of which was Educational Underachievement Disorder. I mean common…now this perfectly normal (quirky but normal) girl is stuck with this label? Come on!!!! The funny thing is, I was with the part of the team that assessed the girl. We had all come to the conclusion that this kid was fine. Then the group who talked with the mom was all, oh no, the kid has something…lets start her on a trail of meds. AND THEY DO!! OMG! I cannot believe this shit! Now we are giving meds to nerdy kids who need our attention? We are taking personality away from these kids. I am pissed!!! The other case I wanted to talk is right along this line. He happens to be a 3 year 8 month old little boy.

I mean. This gross mis-use of our power as physicians makes me, well, it makes me sick. Really? We are starting this girl on MEDS?!! Because essentially her mother wants us to? I mean, what happened to even trying behavioral methods first? Oh, I don’t know, try moving the sister to another class. Try talking to her. Ok, I need to stop. But you do realize how bad this is for children right? Now we have so many kids that don’t need to be plugged into the system, that the ones who really need help can’t get it because there is not enough funds. While these kids, that just needed a little extra time, are stuck with this label, and will most likely be treated differently for quite sometime because of this label. Sigh. It is stupid. Thus it makes me say, Behavioral Disorders My ASS!

So, it has been I week and one day since I left the NICU, and well, exactly one week since I started Step 3. I can’t really say much about step 3 other than it is over and I sincerely hope that I don’t have to take that expensive two day test again. Sometime I wonder just how much richer I would be if I didn’t have test anxiety.

The NICU was amazing. It was stressful, yes, but I had a LOT of fun. I mean, I loved learning about the patients, and most importantly, I loved learning how to take care of the patients. I mean, there is so much you have to know for the NICU, and honestly, so much of it is basic child care, that you wouldn’t know unless you had a baby….which I don’t and probably wont for a while if ever. I mean, I learned about nutrition, why it is that babies need to get 3-4 ounces ever 2-3 hours. I learned how much work it takes a 27 week baby to get to that point. I learned just how much carbohydrate, glucose and protein babies need, and why. I learned how to take care of kids on a ventilator, and how to slowly take them off it. I learned how to put a tube town a kid’s throat so that they can be on the ventilator. Though…I did have two attempts at it, and failed twice, but hey, at least I know how to do it. And it my defense, they were hard kids to intubate. I learned about intracranial bleeds, text book liver diseases that you never think you will see.  I learned just how quickly a life can be taken away when everything seems to be going well. I learned how to do gender assignment on a child with ambiguous genitalia. I learned how to be a detective, and had the chance to be a damn good one. I learned the importance of detail, and I am still working on paying attention to the detail.

But even with all this experience, and all this amazing knowledge that I want to continue building on, even having all this, wasn’t what made NICU so much fun for me.  What made it really fun, and stressful, and a little scary, was that for what feels like the first time in my life, I got to see my hard work pay off, and be recognized for it. I mean, I do work hard, really hard, and I try. A lot of times it feels like it is futile, I mean, I know that eventually, it will pay off, but who knows when that “eventually” would be. But in the NICU, I got to see it happen right before my very eyes. I went home and I read every night, as well as did my board study. I came to work, and was able to come up with differential diagnosis for my patients that were pretty spot on, and that my attendings hadn’t had the chance to fully explore. I was able to hold my own during the pimp sessions. I knew my patients the way a doctor should know her patients. I mean, don’t get me wrong, there was and is still A LOT I still don’t know, but for my first NICU rotation, I kicked ass. My attending told me so, he told me how impressed he was, and how advanced I was. The funny thing was that as he was saying these things, I started to feel really uncomfortable, I mean really uncomfortable. I am not used to getting accolades like that. It was also scary and stressful because I know that he will expect sooo much more when I return to the NICU. Because, well, the first time he was comparing us ( myself and my two other co-interns) to the years above us. Now he has a measure of what we can do, and now we are our own measuring sticks. I am my own measuring stick. So yeah, I killed myself on this rotation, and I don’t know what I am going to do when I am there for five weeks in February. I am nervous, but also a little excited for the challenge. I know I don’t want to let him down, but most of all, I don’t want to let my patients and myself down. (I say that a lot huh?)

To anyone who reads this. You may have noticed that I have fallen very very short of my goal of at least writing weekly. Well, rest assured that it is NOT for lack of things to write about. I mean, this month I am in the NICU. I have had babies born with Ambiguous Genitalia, fights with attending about treating a patient in a manner ( with all my years of expertise) that I don’t believe is correct, and to top it all of… catching a baby from a 400lb HIV positive woman, bringing the baby back to life, only to have her mother name her Jazzeria, or Jazzera, or however the heck she spells it. So, yeah, plenty to write about, but not the time to do it well.

See, I am also studying for step 3, something I hate doing. REALLY hate doing. Not because I don’t like reading about medicine. On the contrary, I LOVE reading about medicine. I mean, when I get home from work at night, and I am tired, I love looking on uptodate.com, or one of my books or journal articles, and I love reading about my kids, and trying to figure out what is wrong more about them, learn more about their disease process, and see if there is a better way to treat them. I love, reading and getting ready for rounds in the morning. I love getting those Aha moments, but studying for these board exams is different.  I hate them, they make my chest hurt, and they are stupid. But it is something I have to do. The last one of these I have to take.  And I just want to get it over with so I can continue to focus on what I love. But it takes time, and if I want to only take this test once, I have to give up something for a little bit, and that is going to be this blog.  Just for a while. Then, when I come back, I will be better, and hence this blog will be better.

You know, I just got back from watching Julia and Julia, and it was great, it made me think about me, and my life, and what I love to do. My three loves, running, cooking and medicine. More importantly it made me think of how I like doing these things. I like doing them in the zone.  Does that make sense? Like when I cook, I mean really cook…either for me or for my friends or whoever. When I am making a meal. I love doing it with music playing in the background, and just focusing on what I am doing. I really don’t want to talk to anyone else while I am doing it. I just like being there in my kitchen, and the food, with the music playing, totally absorbed in the food. Then, there is that stress of making it just right, making it great so my friends or family will love it, not just like it, but love it. That stress pushing me to work harder and better to please others and in turn please myself. The same with running, expect for I am only trying to please myself.. My best runs are when I don’t force it. I wake up, and its the perfect morning, and I feel great, and I just go out the door with no expectations and just run. Just me, my music and the streets. Its quiet, no one is watching me, and I am just alone with my thoughts, but all the while there is this adrenaline, pushing me to go faster and further and to always finish strong, stronger than I started. Always stronger then I started. Then there is medicine. But not just medicine. Pediatrics. I come into work and sit at in front of my computer, and I get this data, these otherwise meaningless bunch of numbers, and I put them together to mean something or at least I try. Then, I get to go and see my patients and try to make sense of it all, and do it for them to help them, but also for me, to help me. That drive is still there, this drive to make them happy and well, and in turn doing something special for me, that I can’t put my hands on, but it does something for me. The same way running and cooking do. There is a chaotic peace about it. I mean, it’s stressful, and scary…but, I don’t know, that peaceful aspect is still there. Then I get to come home, do some reading, and then reflect upon it here. Oh, and of course make fun of some things along the way.

So, even though, I am pretty sure there is only one other person out there who reads this, I do this for that one person, and for me. I want to make this a good blog for that person and for me. In order for me to do that, I have to concentrate and get this odious test out of the way, and I will be back. Until then, remember that just because you love chocolate, roses, and the good Lord, it is not ok to name your child, Chocolate Rose From Heaven God.

Sigh, it has been a while, turns out that the outpatient world is not only a lot more boring than the inpatient world, it also makes me a lot more lazy. So I haven’t really had that many clinically interesting stories to put on this page, lots of other cool cases for me and my case logs, but nothing too crazy. Although…last week one of my patient’s fathers wanted to know how he should go about asking me out. This is of course after we got done talking about the sleeping arrangement between the patient’s mother and him. So yeah, you can guess how that well that worked out for him.

Ok, about this week’s case. This is actually a story about how I messed up. So, I was on call last night. A patient had been admitted to the floor with uncontrolled type one Diabetes. Only he came in because he was having diffuse abdominal pain. So, during my evaluation of him, I did what I thought to be a pretty good abdominal exam, as well as a pretty good general exam. He did have hypo-active bowel sounds. He was more tender on the left quadrant, and a little on the right upper. But he was also really tense and anticipating the pain. I did NOT feel an enlarged liver though I should have done a better job of palpating for one, and I backed off on palpating his spleen because again he was really tender on the left side, I didn’t push it. He looked like he was a little bit ichteric (yellow eyes) but I attributed that to his coloring.

I concluded from my exam that his abdominal pain was from his acidodic state and his mild to moderate ketotic state. I was going to re-evaluate when his evening labs came back. So, I went to bed, checked his labs a little after midnight, they were not back yet, so I figured I would just check them later. I had a couple of calls overnight, nothing to do with him, he was stable, and I forgot about the labs till 6am.  Well, then my senior had checked them around 1:30 in the morning, his liver enzymes were super elevated so she went back and re-did the abdominal exam.  Longer story a little bit shorter, she found his liver to be enlarged, and sent him down for an ultrasound and did a hepatitis panel. I just now checked on the results of the ultrasound and hepatitis panel, and though everything else was fine, the ultrasound showed mild to moderate enlargement of the liver.

So, aside from the fact that I missed a crucial aspect of my exam, an exam that I can actually feel comfortable saying I typically do very well, I let my laziness and complacency put a patient in potential danger. I can’t believe I missed that and I let that happen. And so early in my career. Well, I am glad this happened now, cause I sure as hell won’t let it happen again, and I am glad that my senior had my patient’s back when I dropped the ball.

This is a lesson I will not forget.

I know I fell behind, but thing got kinda of busy, and well, I let myself start to slack a little bit. But I am all good now.

So, the winner for this week ( or the past ten days) is actually a case that I saw today in my continuity clinic. My last patient of the day…and what is the chief complaint? Unusual hair growth. And I am just like…well FUCK.

So I go in to this this 11 month of Caucasian female, and she has about 5-10 course dirty blond pubic hair. No breast buds, no discharge, no axillary hair, no unusual odors, no family history, just pubic hairs in an 11 month old little girl. So, I go and tell my preceptor, and she is pretty much like…well FUCK. We order a bone scan to try and estimate bone age, and we get LH and FSH levels. Which really, upon further reading when I got home, we should have ordered DHEA -S levels.

The good news is that premature pubarche, which is the isolated appearance of sexual hair before the age of eight years in girls and nine years in boys.  Is typically a begnine finding. It is also more common in girls. So if the bone scan comes back normal, then she will be ok. If not, we will really should order the DHEA-S levels because that will give us more information than the LH and FSH levels and take it from there.

But yeah, pubic hair in an 11 month old girl is not something anyone should see, and something I didn’t think I would ever get to see. What a great teaching case.

Words  I never thought I would hear as a Pediatrican, but here they were tonight on my fourth night of call.

Now, you may wonder why we would want to “Bomb” a child. Well, here it is.

So when a child comes in, and the are really fecally impacted. I.E fully of shit, literally. We clean them out with an Enema. The enema of choice is really up to the doctor taking care of them. My enema of choice is Go-Lytely, others prefer Milk of Molasses or some other concuction. Well, this particular doctor that admitted a patient liked the Pole-EE Bomb! This was a new one on me.

So what is the Pole-EE Bomb you may ask? Well it is a rectal supository of gastrografin, mineral oil and normal saline…and AWAY we go. So, if you are ever hanging around a Peds ER, or something like that, and they say they are going to bomb a kid. Rest assured, this is most likely what they are talking about.

P.S for this particular patient tonight. If the bomb hadn’t worked, I would have had to manual dis-empact this charming 18 year old boy. Thank God for the Bomb!

So, this week, I actually have two anecdotes that fit into two different categories. I have one “case of the week” and one “You named your kid WHAT?”

 Case of the week: This one actually came overnight and is a plastic surgery case that we are simply consulted on. A 9 year old female bit her dog in the ear, and the dog bit her back…in the face. But wait there is more. The dog bit her lip off, mom throws the lip in the trash can and then brings her to the ED. Guess she was tired of hearing her daughter’s lip. (Please laugh, I worked really hard on that one). But no worries, this story has a happy ending. Plastic surgery had the mom go back home and fetch the lip and they were able to re-attach the lip. As for the Dog, well, his ear is ok and the family is not blaming the dog.

 You named your kid WHAT?: Mister Morris IV. Oh, you want to know what his first name is? His first name is Mister. Yes folks we have a Mister Morris the Fourth. Sigh. Yes, the family was black.