The First Fourteen Days

Well, I finally made it to my first day off, and well, I didn’t kill anyone. This month has been kicking my arse all over the place and it’s not even half over yet. So much has happened, I don’t even know where to start. So we will try it like this.

Week 1: I was the senior resident who had to give a previously healthy 17-year-old girl and her family the diagnosis of severe metastatic Ewing sarcoma. Translation, really really bad cancer, that has a less than 1% five-year survival rate. Found out that one of my long time patients ( since I was a medical student) died at the age of 14, very shortly after his 14th birthday actually, of leukemia. Realized that my co-senior was a controlling, power loving, power tripping, condescending, obsessive compulsive wench. Had to tell a lovely family that there was no medicine that could fix their little 4 month old daughter, even though we used medicine to bring her back to life when we probably had no real business doing so. Realized that I had already worked 67 hours in 5 days. Diagnosed a 3-year-old, previously healthy boy with lymphoma. Realized that no matter how hard I worked and tried, it would never be good enough for my attending who only sees me as a meer second year senior, and thus can’t or rather isn’t capable of doing anything as well as the previously described 3rd year senior. Had an emotional break down in the bathroom in the middle of the work day, and just cried in the bathroom for about five minutes, then at the end of the day, proceeded to cry in my car on the way home, then cry myself to sleep. All the while not really understanding, or knowing, why I was crying. Finished the week by getting elegantly tipsy with the whole team, including the attending and the medical students at happy hour on Friday.

Week two: Started on Saturday. New attending. Much more experienced attending.  Did my first totally unsupervised LP, in which I was teaching the intern how to do the LP. Nailed it on my second try. Had my first night of call in the Pediatric ICU. There I learned the three-year old with the lymphoma was slowing getting better with the chemotherapy, but was still intubated. Met a little boy who was adopted from Ethiopia, only to get the crap beat out of him, and have his brains bashed in by his adoptive parents. Got the chance to see this kid slowly get better each day to the point where by the end of the second week he was able to talk, and move, and may even get to get his skull put back in his head. I realized that I was going to have to be more assertive with my co-senior and not let her walk all over me, but I was just going to have to let some things go, but well…I also realized that she really can’t help herself. My brand new interns were getting the hang of things. Hadn’t gone running for 15 days in a row.

I know there are somethings I left out. So much happened during those days. My days were so long, and that first week, I was so miserable. I couldn’t even enjoy my work. All of it had to do with the team dynamics. Let me tell you, it was really awful. I was really tried. I couldn’t wait for today. I mean, I got to sleep in till 6:30, didn’t actually leave my bed till around 7:20. I finally went for a run. I mean, sure, I was already 85 degrees outside, but I still loved it. I still needed it.

Being a senior in July is hard. You have brand new interns, brand new responsibilities, and you have to figure out how to find balance again. It’s hard. This time last year I also had the luxury of only having to focus on work. Now I have other things in mix and I have to find time for everything, without losing myself. I needed this day off, cause I am not sure how much longer I could have gone. It was tough. Yes, it’s getting better, but I don’t know. I am afraid of every call I take because I know I will be covering the pediatric ICU, and I am still so not comfortable with that. I am still so scared. I haven’t even read at all yet. No educational power points. No nothing, I do plan on reading today, but still. Its a lot.

I am just not comfortable with this new role yet. I guess, it has only been 14 days, but still. I am petrified, and well, tired too!

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Crossing the Line: Out of Intern, into Second Year

Once again I took a little bit of a hiatus before coming back. Since I have been gone, I have found new found respect for ER doctors. OMG! I don’t know how they do what they do. I mean honestly. 40% of their patient population are people who use the ER because they don’t have a primary care doctor because they can’t afford them, (no insurance) another 40-50% of the patients, and actually, let me correct that, 40-50% of the adult patients are malingering, drug seeking punks of the earth, or people who just need a place to come in to get some warmth and a nice sandwich. The rest are either dead or dying on arrival, and then, the few that actually have a legitimate serious, emergency department problem. Its no wonder that ER doctors are probably the most jaded disgruntal doctors you will ever meet. They are also the smartest, at least, the good ones are. I mean think about it, they have to wade through the bullshit and find those 5-10% percent of the population who have an emergency, or worse, whose nagging pain is actually cancer or something hopefully not so terminal, but yet still serious. Then, the really good ones, will also realize that we, the doctors are probably the main reasons we HAVE drug seekers. I mean, we were the ones that prescribed them narcotics for their menstrual cramps because we just wanted them to stop coming in and complaining on it. Or we were the ones that didn’t write a taper for the narcotics and just trusted that they would stop taking the pain meds when they stopped having pain. You see, the really good ER doctors will realize this, and still give these drug seekers the time of day, take responsibility for being a part of the problem, and try to slowly wean them off the heavy stuff.

Next, I was in the full term nursery, and I LOVED IT!! I loved playing with the babies, I loved talking to the mom’s, and I loved learning from both the babies and the mothers. You know, all my friends that already rotated through the nursery said that I would hate it cause I would be bored out of my mind. But, I really wasn’t. I mean, if you think about it, as a pediatrician, what do your pregnant friends or mother friends and relatives ask you about? It certainly isn’t about how much fluid you should give their sickle cell patient or how to manage cystic fibrosis from an inpatient prescriptive. No, the questions they ask you is about their newborns, their toddlers, things we see in clinic. I think that clinic and Newborn nursery is the bread and butter of pediatrics. I really do, and I want to be damn good at it, so I was able to take the time to read, and study and actually apply everything to work everyday. It was pretty awesome. When I did that, this rotation was just as educational and almost as intense as the neonatal intensive care unit. It was awesome. Not to mention all the crazy as stories I got out of it. Yeah, there were a couple of times, I should have just logged on, and wrote them down because they were hilarious. I mean, from a 16 year old mom who got pregnant from her baby daddy, and had him in the room at the same time as her husband, to the dumb ass names people still insist are cute and ok. Like Destiny, Semaj (James backwards), and my personal favorite; First Name-New; Middle Name-Hi; Last: Riseson. Yes folks, this bouncing baby boy’s name is New Horizon.

Now, for the past month, I have been on Junior Ambulatory, which is essentailly a bunch of continuity clinics (which again, unlike my fellow residents, I love), shadowing social workers, nurses, and other people that make our clinics run really well. It has been awesome. I have also had the chance to work on implementing a community and advocacy rotation into our curriculum, which is AWESOME cause that is one of the reasons why I am at my current residency program. It is one of my goals, and I really hope I get to make it happen. The rest of the time, well, I have been freaking out because….well…in three days….I….will….be…done….with…my….INTERN YEAR!!! I used be excited that I actually made it a year, and I haven’t killed anyone yet, and I am actually, slowly, very slowly accomplishing some of my goals, but I am SCARED SHITLESS. I haven’t killed anyone because I had layers and layers of protection. I am supposed to protect and teach an intern? I am supposed to teach medical students? People are going to be asking me questions? Are you kidding me??!! I am not ready to be a senior?? OMG!!!

Ok, breath. Just breath. This is in fact a milestone. This is the first of three finish lines till well, I get tossed into the real world. F!! I am going to go back and doing some studying. I plan to be back by July 1st. I hope to have some time to let you know how it goes. July 1st. Starting where I started as an intern. The inpatient floor. Now, this July 1st…a Floor senior.

I hope you are ready for another year of adventures!

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Being A Doctor is Hard

It seems almost too simple a statement doesn’t it? But it really is. I mean, it is easy to forget just how hard of a road it takes to get here, and the things we deal with and see on a daily basis. How do we keep our humanity? We are in school for a minimum of eight years, that is for those of us who were lucky to get in on our first try. Then we work, we work so damn hard. We lose our boyfriends, our girlfriends, our husbands, our wives. If we, God forbid, get sick, we can’t even take the time off to fully recover because we just have to keep on going. We move our families place after place to get into medical school or we leave our family behind to go to medical school. A loved one dies during the process, and we can’t even really stop to process our emotions, we just keep going, and going. All the time trying not to lose ourselves in the process because at this point it is all we feel we have left. Then, after the grueling process, there is still a good chance you get your heart broken because you didn’t match. You didn’t get accepted in to a residency on your first, second or even third try. But lets say you do, you get your residency, you can’t really get sick during residency because now you are really practicing your craft. This is the time it counts the most, this is the time you have to hone in your craft and study and work like hell because even though at some point you will make a mistake that will inevitably cost someone their life, you want to put that off for as long as you possibly can. Lets not forget that during this process you can still be dealing with the situations above, but now you add depression. Depression because you do lose your patients, because you are so tired and overworked, because you miss what its like to have a normal life. Then, lets say you make it out of residency, you are almost done, and you get to finally do what you have wanted to do for what feels like all of your life. Then what happens? You find out you have some terminal disease.  Being a doctor is hard. The only thing that makes this finishing this journey possible is my faith, my social support, and the fact that I do actually love what I am doing. But dang it’s hard.

You would think that after my long hiatus from my so called monthly blog, I would have something more profound to say. Perhaps talk about my first emotional breakdown on my way home from work in which I just called my best friend and cried. Or the first time I lost a baby. Or hell, my NICU babies named Snow White ( black Female) and Sir Elton John ( black male). I could have, and in fact many times since my last post, I have wanted and started to, but for one reason or another I didn’t. Why now? Because its been a fucking (excuse my language) long winter and in the midst of everything, this is what I took away, and this is what I have to say. People think “oh doctor, must be good” or the many idiots out there who think doctoring is all about the money. Who the hell would go through the above to make money? I mean, really? Money? Prestige? No my friends, even the plastic surgeons who do nothing but boob jobs for stupid stars went through this hell. If that is what they want to do, if that is what they fought this battle to do, then more power to them.

This is an almost angry post, but I am not angry. I am actually just scared. I see things and hear of things that are happening to my fellow war buddies, and I wonder when my turn will be? I don’t let fear stop me, but its like I have this cloud over my head, and I am a little nervous. In a few short months I will be starting my second year as a senior. Then another year and I will be done. What will happen next? Well, I guess when I find out, you will too.

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My First Bad Day

Yes, I know, it has been a while since I have written…I fell behind. But in my defence,  there was work drama, emotional drama, the holidays, and being  sick…. Ok, so no real excuse except for I let myself slip. But I have had great ideas for posts, and I have been working on them, just haven’t logged on to post them. SO, here we are. This day that I am about to post happened on November 20th. Thats the bad thing about being a resident. Bad days can last 12 hours, 24 hours, 30 hours or a whole damn weekend. In my case, it was the last two. So, here is the story.

So, there was a seven year old female with Pneumonia who came in with it in her right lower lobe and right middle lobe of her lungs with effusion on 11/10. She has had a pretty complicated course, was in the PICU, and then transferred back to the floor on Thursday 11/19. While in the PICU she was on three antibiotics, one of which was vancomycin. Prior to transfer to the floor, the PICU team decided to stop the vancomycin, and continue on the two antibiotics. Friday, we rounded with Dr. A, the old floor attending, and Dr. B the new floor attending. We presented the patient with the current antibiotic regime and the improving clinical and lab picture. I bring up consulting Dr. C (the infectious disease doctor) for discharge planning ( what abx will she go home on) and what we could do with her antibiotic coverage now. Dr. B did not feel that Dr. C should be consulted because he could not come and see the patient, and evaluate the patient. Dr. B made it very clear that she wanted Vancomycin added back onto the list of antibiotics she was taking. Before I could go into the patient’s room, my senior lets me know that we have two admits, it is after 11:30 and we still had more patient to round on. I write the order to add the Vancomycin back and to get a CBC and CRP at that time. I go in the patient’s room where she is making it clear that Vancomycin is the only antibiotic she wants the patient to be on. She also makes it very clear that she wants the other two stopped. No questions asked. What I should have done at that point was to go back outside at that moment and stop the other two antibiotics. But I didn’t. I instead go and ask Dr. A her opinion because I did feel uncomfortable stopping the meds that had been working for her. She tells me that Dr. B is the attending, and she is making the decisions. She did recommend getting Dr. D’s ( our pediatric pulmonologist) input and perhaps as an ally. I was content with that and was going to write the order to stop the other two antibiotics, but I wanted to try one more time to reason with Dr. B. When they came out of the room I asked if before we stopped the two antibiotics if I could bring in some literature to show why I thought the current regime would continue to work for her. I asked to wait and see what the numbers come back as before changing her current regime. It was clear what my opinion was, she said no, and I accepted my defeat. At this point, My senior tells me we have to hurry and finish rounds because we now have four admits. It is just my one senior, and myself. The other intern was post call and the other had the day off. Dr. B agrees, we should hurry because its almost noon, we have noon lecture, the students have noon lecture. So we hurry finish rounds, after that I go on to do the admits, long story short, the order to stop the other meds doesn’t get written. Latter that evening before I do night rounds, I am going though patients’ labs and general to do lists. I look up this patient’s infection markers. All the numbers are trending downwards, by labs she is continuing to improve. I tell my on call senior this as well, and also tell her that Dr. B wanted me to stop the other two.  We agree to leave them, as she as been getting them all day, she is getting better, we can present the numbers to Dr. B if she still wants to stop the abx, she can in the morning. Again, here I accept fault. When I realized that the order was not written at this point, I should have just gone and done it.

On night rounds, the parents state that they are not happy with the vancomycin. That the are confused as to why everything is changing when they had one plan in which their daughter was improving on. I state that the patient should just be on the vancomycin as was stated to them earlier in the morning, but that I did not write the order in time so she is still getting the two. I did say that with Dr. B’s experience, she feels that vancomycin is the best drug. I then went on to say that she was improving on the regime that she was on right now. I told them the numbers. I did tell them,that  I would let Dr. B know that she ended up getting the three antibiotics instead of the one, and that we would go on from there. They again voiced that they didn’t know why things were changing, if things were getting better, why things were changing. At this point, I said that Dr. B would talk to them about that more in the morning, and that she was improving, and that we would do our best to make sure that she would continue improving. A little later in the night, I get report from the nurse that she was having what seemed like an allergic reaction to Vancomycin called Redman’s syndrome, which is common with Vancomycin.  I gave the order to give the benadryl, which she got, and I received no further complaints.

The next morning during rounds, we start with my patients since I am post call. Things are going well till we get to this particular patient. I tell Dr. B that I didn’t get a chance to stop the other two antibiotics, she cuts me off, tells me she is not happy, takes the chart, writes the order to stop those two antibiotics and then goes into the patients room. Myself, my two other fellow interns, my senior and two medical students quietly follow her into the room, and well, the real drama begins.

Dr. B tells the family that she wants the patient to only be on one medicine, the Vanc, and that didn’t happen, but she made sure it would happen now. The patient’s mom tell Dr. B, that she is actually happy that the other two medications were still running, because she feels that her daughter is getting better, and that the other medicine ( the vanc) was making her get red and itch. Dr. B says that we can fix that, but that with her 15 years experience, she feels that vanc is the best medication for her daughter. The parents tell her, well, no offence, but they don’t really know Dr. B, and that she is coming in, and changing the plan, when the plan is working for her  daughter, and she would like to know what the rest of the team thinks. At this point the rest of the team…myself included, just kind of look at the floor, and avoid eye contact. Dr. B says, well, that though we are great doctors, but we are still learning, and she has more experience than we do, and that she is the one who ultimately makes the decisions.

They two of them go back and forth, and it grows VERY uncomfortable in the room, the mom keeps building the team and myself up while we, and especially me continue to sweat and shrink under her comments. Finally it comes to a head and the mom says I want to know what they think (she points at the residents at this time), they have been with her from the start, they know her, I know they care about her. Man, it was awful. No one says anything. Dr. B looks at me, and says “answer her!” So, I do, and I say what I feel. I say I think we should keep it all on board and consult an ID doctor to find out what the best medication is. My two fellow interns back me up, the students are shitting their pants. The mom looks at my senior and says, you too, what do you think. He says there is no right or wrong way, that there are many different approaches that can bet taken. (Wish I had thought about that!) Anyways, it was awful. Dr. B backs down and says fine we will do it  your way and storms out of the room.

Outside of the room, she looks at me, says she is not happy, that infact, she is pissed, and will be back in half an hour. I try calling her, to try and explain. But she would have none of it. She tells me that she will talk about it on Monday with the Residency Program Director, the Chair of the Peds department, and the Pediatric inpatient floor director. I was pretty sure I was going to get kicked out of the program, and I went home that Saturday depressed. What’s more, I kept getting pages and phone calls regarding the patient’s mom, who wants to talk to me, because she doesn’t like Dr. B, and thinks she is crazy. The patient’ s family ends up transferring to another hospital.

Well, luckily this story has a happy ending, as I still have a job. The meeting that was supposed to happen, never happens because my program director sides with me and realizes that I didn’t do anything wrong and that had evidence based medicine been used, none of this would have happened. However, I should still apologize to Dr. B for my professional well being. The patient when she was transferred to the other hospital was placed on the two medications that we originally had her on, that team consulted a Pediatric Infectious disease specialist, she recommends an entirely different medication and she gets well enough to be discharged the next day. That family finds me, and I am now the pediatrician for that patient and her two other sisters, and I have seen her in my clinic twice since the incident, and will see her again in January. Dr. B and I are cool. We worked together last month while I was in urgent care. We are professional and cordial to each other, and even smile. Heck, we are still facebook buddies. But things have changed. I used to really like and respect her, and that is all gone now. I no longer respect her, and I am sure she feels the same about me.

The thing is, Dr. B has had this reputation for being well…crazy, and sometimes making poor clinical calls. I used to stand up for her, now I am just quiet. It sucks. I was placed in a horrible position, and for better or worse, I stood up for my patient, and I learned A LOT from this experience. I really don’t want to be in this position again. The truth is, I probably will be in a situation like this again, but I will know how to handle it differently now. Hopefully better.

I never, NEVER EVER want to hurt a patient. I never EVER want to let my ignorance, ego, whatever get in the way of doing right by my patient..but what if I don’t know what that is? I mean, Lord knows, I will always ask for help, but, what if I think I am doing right by my patient, but I am not. Then what? What happens if you not only don’t know what the right answer is, but you don’t know how to find the right answer?

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A case of Uncontrollable Laughter!

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.

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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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