Archive for October, 2009

The Edge

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Last night, or I guess two nights ago now, I was on call. Things were actually going pretty smoothly considering my usual call night. I had tucked all my patients in, and was going to hang out with one of my pre-teens in her room for a little bit when my senior tells me that there is a patient in the Emergency Department that we have to check out. The patient is a 2 month old baby that was just diagnosed early in the day with influenza but had a febrile seizure, and the ED doctor wants us to evaluate him and decide if he needs to be admitted.

So, ordinarily, a child under 18 months of age who has a fever of unknown origin, with a seizure, NEEDS to have the full work up done to rule out meningitis.  That said, we go and look at this kid and talk to the mom. I asked mom what happened. She tells me that about 45 minutes after she had given her baby tamiflu (the medication we give to treat the flu) she noticed that her baby had two jerky movements and then smacked his lips for about five minutes. During this time, she took his temperature and it was 102.2. She then called the emergency response team, but the time they got there, the baby had stopped doing what ever he was doing, and they brought him to the emergency room. On arrival, the baby was still febrile. They gave him some motrin, did some blood work, collected blood cultures and called my team. When we arrived to evaluate the baby, he was no longer febrile, he was happy and smiling, and well long story short, his physical exam was perfect. His vitals, when I checked his heart rate, it was a little fast, 150, but otherwise everything was good. While we were in the ED, his lab work came back,  and there was no indication of systemic infection. Blood cultures were not back yet. After getting the history from his mom, and evaluating him, we called our attending who was on call. Told her we decided that he did not meet criteria for inpatient admission. She agreed. We wrote our consult note, and told the ED doctor, who seemed a little surprised but said ok.

About two hours later, we get a page from the ED doctor who says that he spoke with ANOTHER attending, (not the one that was on call with us first) and they decided that the baby needs to be admitted for a lumbar puncture to rule out meningitis and started on antibiotics. He also stated that after talking to this other attending and then calling our on call attending to tell us the plan, we needed to come admit this baby.

Three things: 1) WTF? You are going to go behind OUR back, talk to another attending who is not even the one on service and then decide on the plan??!!! REALLY??! 2) THAT attending is then going to make this clinical decision without seeing the baby or talking to US, the team that evaluated him??! 3) If the ED doctor really believes that this baby meets clinical suspicion for meningitis, then the AAP guidelines are clear, do the lumbar puncture in the ED and start the kid on antibiotics right away.

So, what happened? I am pissed, and I go to bat for this mother and her child. I called our attending, and told her our evaluation. I told her that if she, or the other attending was there, they would NOT do an LP on this baby. If you want to admit him overnight for evaluation, fine. I get that. Lets hydrate this baby, watch him and see what he does. Then the question arises, what if they really were seizures? You can’t call them febrile seizures cause the kid is under 6 months of age. However one of the side effects of tamiflu is seizures activity. What are associated symptoms of having the flu in babies? SEIZURES. But I get it, you rule out the most devastating disease first, and then you can attribute the “seizure” to the things I listed…but only if you think the kid had clinical suspicion for meningitis, but HE DIDN”T!!!  Why put this little baby through an invasive procedure when he didn’t need one. But it didn’t matter what I said. It didn’t matter what my senior said. It had been decided by those who never laid eyes on this kid that he was going to get a lumbar puncture.

So, there I was. All gowned up and ready to do a procedure I felt was medically unnecessary on this child who is not sedated, does not have anything to help with the pain he is about to undergo except for sugar and a pacifier. As I inserted the needle and heard his screams of pain, and saw that I didn’t get any fluid out, I felt like I monster. I tried again, still no clear fluid. Then my senior tries, and she can’t get it. We decided…enough. Called our attending back, told her we couldn’t get it, and now she is stuck. What should we do now? We have admitted him…tortured him and to no end. We start the antibiotics and try again in the morning. True getting a culture from the CSF would be useless since we started the antibiotics but we could still follow the cell count.

So, first thing in the morning, my floor senior comes, and this time, he does it, and I am holding the baby, and that is what pushed  me to the edge. I felt so much anger and frustration, I felt so powerless, and as I was looking at this baby, holding him firmly in place, my heart breaks. But I can’t cry, I tried to fight for him, but I failed him. Because I am an intern. I know, I have never been burned by sending a kid home and then finding out he is deadly ill. I have never missed a serious diagnosis. I know I don’t have the same clinical experience as my attending. I know all of this.

And all emotional dramatization aside, I do see why what was done was done. I do. Bottom line, I was not 100% sure that the baby didn’t have a fever. I was not 100% sure that if he did, it was more likely due to the flu and the medication. The baby was less than 18 months of age. The clinical manifestations of meningitis are subtle, and easily missed. The fever may or may not have been due to the flu. I understand. But here is the thing. Though I may be young clinically, I do know that medicine is not a perfect science. We are never going to be 100% sure. We are not God and we will never know. But we are trained to think. We trained to use what we know to evaluate a patient, and to do no harm to the patient. The reason why we are put through this rigorous training is to use our minds and all of our other senses. I know that, had the outside attending or my floor attending seen this baby, they would not have done the lumbar puncture. If they are going to let us residents be the ones to stay up all night in the hospital, then they need to learn to talk to us and trust us.

I think this night of call was a learning experience for all of us. I did talk to the other attending in the morning, as well as my floor attending. We all agreed that the situation could and should have been handled better. I learned why the attending felt a lumbar puncture could have been appropriate in a situation closer to this.  Still, Thursday/Friday was the first time knowing in my heart of heart that I did a patient harm. The worst part is, I now know what my attendings know.  That no matter how much I read or learn or how good I get, there will be that one patient. That one patient that in hindsight I should have done this, or that, but I didn’t. The question is, how will I let that affect me.

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A tale of Two Eight Year Olds. Part one.

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Do you remember what it was like to be eight years old? Try. I was in the 3rd 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  11th 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.

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Behavioral Disorders My ASS!!

Stewie

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!

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I’m BAAAACCCK!

happy baby!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?)

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