Newborn Nursery

… is the closest medicine will ever get to an assembly line.

Sure, I have a certain appreciation for how evidence-based newborn medicine is: The NRP algorithm (the process we go through with neonatal resuscitation) is rock-solid. The science is satisfyingly pure physiology. There is no Past Medical History. If the baby so much as blinks at you funny, you simply send it to the NICU for a rule-out sepsis work-up.

And the answer to 99% of new parent questions is “Ah, that’s perfectly normal newborn behavior. Your baby’s body is just trying to figure out how to adapt from being in a dark swimming pool to being in the outside world.”

… literally, that’s pretty much the stock answer I use for almost any parent question.

Sure, I like to change it up a bit sometimes – for newborn congestion I’ll say that it’s the baby’s mucous membranes that are getting used to air instead of water… for erythema toxicarum I’ll say it’s the skin cells… occasionally I’ll have to talk about in utero positioning or birth trauma, sure, but… largely, everyone’s simple.

In fact, I’m getting this weird phenomenon where I really enjoy nurses stopping me in the hall to ask me questions. There’s no dread! No sinking stomach feeling! No problem I cannot solve with stock answers!

No matter what the RN asks, the answers are always so clear! It’s so different from general peds! It’s either

  • “Oh, really? Let me take a look and then we’ll notify NICU.”
  • or “That much weight loss? I’ll go talk to Lactation.”
  • or “OK, I’ll put in the order for bili lights.”

And newborn exams are beautiful. Sure, sometimes, when the census is full, I wish I could just line up all the babies in the hallway and do a slow-mo run down the hallway high-fiving all their anterior fontanelles (“Soft and flat! Soft and flat! EVERYBODY’S SOFT AND FLAT! And I’m done with pre-rounds.”)  to improve my efficiency, but usually I’m okay with going to their rooms individually.

I guess the biggest problem is that newborns are essentially just fat irritable potatoes.

I really miss being able to make faces at babies old enough to laugh or mimic my dumb expressions.

I think I even miss the babies who are old enough to shoot me skeptical looks.

Mostly I just miss babies who are real, live, people.

ONE TICKET BACK TO GENERAL PEDIATRICS PLEASE.

(One more week…)

Peds Urgent Care

“My baby has a cough. Does he have ebola?”

No.

“My son got this lump on his neck right with his cold, do you think it’s cancer?”

No.

“Lovely presentation. Do you want to do any work-up?”

No.

“What about a CBC, CRP, LDH, LFTs, Monospot, and CXR?”

No.

“Okay, we’re going to get them.”

Okay.

“Do you think this kid needs to be admitted?”

No.

“We’re going to admit him.”

Ok.

“It’s a soft call, but it’s a Friday, and I have 32 years of experience. This is where experience tells you if a child will get worse before he gets better.”

Ok.

“Uh, thanks for calling me – most interns don’t remember to call the floor senior before a new admit – but I’m confused… Why are you admitting a totally stable kid?”

Because it’s a Friday. And my preceptor is citing his experience. So, you know.

“Okay. Does your preceptor have any idea of what we’re admitting him for?”

Well, either the lump in his neck will turn out to be a deep neck infection that will cause him acute respiratory distress and send him to the PICU, or it will not. So watch out for that.

“Thank you.”

Anytime.

“My baby is here for his well-child check.”

Your baby is blue.

“He is here for his well-child check. How many shots will he be receiving today?”

He will be receiving resuscitation. Incidentally, why is your baby blue?

“I will need a note for work. Saying that I was here for his well-child check.”

We are calling a code.

“May I have a note now?”

You may not.

 

I just – when were we supposed to learn how to wrangle babies? WHEN?

I feel like I generally actually do a really great job with kids –  but somehow seniors only see me at my worst moments.

Case in point: This morning I was on pulmonology consults, seeing a baby in the PICU. Baby was lying face down and I wanted to listen to her heart, so I gently turned baby face up….

… and oh my god, guys – this is not a thing you should do in the PICU. She immediately thrashed all 4 of her tiny limbs and got herself enmeshed in ALL OF HER WIRES which between the 12 lead EKG, the IVF, the pulse ox, and good god I don’t know what else – this baby was slowly strangulating every extremity and neck on her body.

Basically, my physical exam was only good enough to verify that she did, indeed, have only 4 extremities enmeshed in cords, and 1 neck that was flirting with her EKG leads.

So I sat her up and quickly started the process of untangling every wire which she seemed dead-set on ending her tiny life with (as she HOWLED) and the PICU senior actually came in the room cause the baby was crying so hard.

The PICU senior looked at me.

“Hi,” I said helpfully.

“Ah, good… okay… glad pulm is here,” he said. “Um.”.

“Yes?”

“So… the baby’s only 9 months old. Please don’t sit her up like that. She’ll fall and bang her head on the side of the crib.”

Apparently I had done such a good job untangling all her wires, right in the nick of time, that it now looked like I had just sat her up for the physical exam just, you know, for funsies.

“Right,” I said, clearly expressing this complicated concept “Yeah. No, you’re right. Sorry.”

I laid her back down. She glared at the world at large.

“Cool,” said the senior. He left the room slowly, backwards.

The baby waited patiently for him to leave. Then she immediately flipped onto her stomach and enmeshed every extremity and neck on her body in wires again.

10 minutes later, I ripped off my contact/droplet precautions and met the primary team in the hall.

“Um,” I said to the nurse, with all the brilliant dexterity of the best of interns. “So… I think I untangled her wires. But she’s kind of thrashing around and maybe you want to check? I’m not sure? She’s really upset.”

The attending stared at me. I had probably interrupted him.

“Cause I don’t want to undo all your hard work or anything,” I helpfully added.

The senior was pretending to be extremely interested in the nurses milling about across the hall.

The nurse sighed. “Okay,” she said.

“Great….” I said, walking backwards.

“Great.”

Bronchiolasthma Is Upsetting

Half of our attendings believe that there is an Asthma plan and there is a Bronchiolitis plan – and by mixing the two you might as well be burning incense and chanting ritual Latin over the soon-to-be dead-of-malpractice baby, you non-EBM heathen, you.

… Honestly, their clear-cut attitude greatly appeals to my Evidence-Based soul.

But the other half of our attendings will not take kindly to your clear-cut plan. They’ll just ask you where you got those 10 slabs of stone engraved by God with the Official Universal Rules On Exactly Where The Airway Inflammation Resides In This Particular “Bronchiolitic”.

Who are you to say that a trial of albuterol is pointless just because it’s bronchiolitis? they ask. Are you 100% sure it won’t help?

… and they probably have a point too. Right? I mean.. it makes sense that all inflammation is a continuum and could happen in multiple locations, so why not trial albuterol?

But I’m sick and tired of admitting kids for respiratory distress just to get mocked for my inability to Adhere To Established AAP Guidelines (if the attending falls in Camp 1) or Understand That Airway Inflammation Is A Continuum (if they turn out to adhere to Camp 2).

I didn’t get into medicine just to stake my supposedly scientific plan solely on the attending-of-the-hour’s personal ideology when not even Nelson can explain this shit to me.

but why i need to know why

The Respiratory Therapists are no help, either. My favorite RT once told me:

“It’s not so much a matter of where the inflammation is – what you’ve got to remember is that kids don’t even have bronchiolar smooth muscle until 2 years of age, so even if they ARE asthmatic, albuterol won’t help. That’s why some people say there’s no point to the albuterol trial.”

Which sounded like the solution to all my problems until I actually looked it up. (Spoiler alert: not true).

everything was making sense and now it doesnt

So I bit the bullet and took a pediatric pulmonary elective. Because the Pulmonologists should know, right? THEY SHOULD HAVE THE ANSWERS.

And my very first case of “This is definitely, 100% verifiable on formal PFT and albuterol testing, clear-cut URI-triggered asthma”… what does the Pediatric Pulmonologist diagnos it as?

Bronchitis.

BRONCHITIS.

MOTHER-EFFING FULL-ON ADULT BRONCHITIS because fuck you, that’s why.

igiveup

I hereby rescind all my respect for the respiratory tract. May god have mercy on its stupid, alveoli-filled soul.

This shouldn’t be so hard. Air goes in, air goes out – unless it’s blocked by inflammation, which should be able to be attacked by obvious anti-inflammatory measures, unless it can’t be because of, I don’t know, reasons no one will ever tell me.

Screw you, lungs.

opening wine confidence

Family Centered Rounds Are Bad

Normal Rounds:

Attending: So GI recommends a neuro consult, huh? Do you want to get one?

Me: Well, the patient actually has neuro outpatient follow-up scheduled in two weeks and no acute issues. The relevant genetic labs were drawn yesterday and will likely be pending for at least a week. And after speaking to the GI fellow, I believe he recommended we consult neuro as a way of tacitly implying that he thinks the GI consult was dumb.

Attending: Neuro wouldn’t want an MRI or anything? Nothing we could do inpatient?

Me: Well, a head ultrasound was normal, all he has are diffuse LMN signs without any focal abnormalities on exam – and dysmorphism alone isn’t an indication for a head MRI, especially with pending genetic labs… so…. honestly, definitely not.

Attending: Well, at least curbside neuro – if they agree, the family can go home today.

Family-Centered Rounds:

Me: So, sounds like we’ve gotten all the worrying symptoms under control! Do you feel comfortable going home, or would you prefer to stay another night?

Mother: No, I feel great! So relieved about the new medication. My ride should be here this afternoon!

Attending: Actually, GI floated the idea that we should get Neuro involved – they might want an MRI or something! We could get that done inpatient for you. What do you think?

Me: …!!

Mom: … well, I don’t know… would it help? Do you recommend it?

Me: erm.

Attending: Well, it couldn’t hurt! Here’s how the MRI would go: he likely wouldn’t have to be sedated, cause he’s so small, and I bet we could get you on the schedule for today!

Mom: Well… okay then!

Me: :(

Status-post Family-Centered Rounds:

Neuro Fellow: Okay, so the kid has no acute issues and outpatient neuro follow-up already scheduled. What are you guys consulting us for?

Me: …. the question of whether a head MRI would be indicated.

Neuro Fellow: …

Me: Today. Stat.

Neuro Fellow: Without any focal abnormalities or UMN signs? Really? You’re consulting us for a head MRI for diffuse hypotonia?

… Hey, wait a minute – aren’t you supposed to be in our program in 2 years?

Me: …. that’s… that’s another intern. I’m someone else entirely. Please forget my name immediately, thanks.

My Suprachiasmatic nucleus is SO MAD at me right now

Assessment: 27 yo intern p/w erratic sleep schedule s/p rapid night-day scheduling shift, at risk for impending circadian failure. Post-sched-chng Day #1.

Plan:

  • NPO for AM rounds d.t. professionalism
  • Post-rounds may PO caffeine ad lib, goal volume 200 mL QD
  • Rapid caffeine taper 4 hours prior to end of shift
  • Will not monitor I&Os; could not care less frankly
  • C/s Taylor Swift for reccs on afternoon dance break
  • Dispo: neverrr

A Typical Morning Sign-Out

(Alternate title: The nurses are correct when they think we’re hopeless idiots.)

Me: Any questions on Bed 18? Great, let’s move on to Bed 19…

Pager: *BLARES*

Me: Hold on.

Pager: Bed 32 is nauseous. Can she have Zofran order before I give her her scheduled meds please?

Me: Um… hold on… we haven’t gotten to this patient yet and she really needs to not vomit her morning meds. *types in order for Zofran* Okay, back to Bed 19 – he’s here for dehydration but mom is refusing an IV. Discuss.

10 minutes later

Pager: Thank you for the Zofran order, but Bed 32 has never had an IV. Can you write it for oral?

Day resident: UGH. Okay, hold on – let me fix this. *types oral Zofran order* Where were we? Bed 25?

Me: Right. Okay, back to bed 25… gonna need dialysis as an outpatient, gotta figure out how to coordinate the gentamicin with the dialysis. Do we need to write an order? Or does nephro do it? We have to figure this out by 10am or the hospital will get dinged.

Cross-cover Resident: Um, also I just got paged that Bed 42 is vomiting blood.

Pager: THANK YOU FOR THE ZOSYN ORDER BUT SHE NEEDS ZOFRAN. AWAITING NEW ORDER, THANKS.

Me: …

Day Resident :…

Me: Can we just like, outlaw pages during sign-out?

Day Resident: Can we ignore it and hope she doesn’t call a safety event on us?

Cross-cover Resident: Let’s smash the pager with a hammer and go home.

Pager: *BLARES*

A Magical Yet Impractically Secret Phone Number

I’ve spent two days, on and off, working on that last blog entry – but somehow I still didn’t anticipate it would scare people.  I was surprised to see so many comments and messages this morning.

Turns out maybe there’s no way to write about untreated anxiety / depression in a non-scary way. Interns really shouldn’t be working 80 hour weeks with untreated anxiety. It’s a recipe for a bad time even though I feel like I’m handling it well.

(That’s usually the difference, isn’t it? We all want other people to seek help immediately, but when it comes to our own health, medical people have a deserved reputation for being dilatory as hell.)

So. Okay.

I had brunch with a co-intern who I deeply suspected had gone through the same damn thing – and luckily, I was right. He gave me the name of the NP whose job is to see residents for free and make every effort to get them into clinic at a moment’s notice. I’ll get an appointment tomorrow.

I should feel relieved.

Instead, I’m honestly a little irritated that our hospital employees medical professionals explicitly for this purpose and then makes it impossible to find out about them. (Short of having a terse, scary meeting with the Program Director – which is how my co-intern got the numbers in the first place.)

Why make this so hard? How counter-productive is that? Why are hospitals so universally dumb?

… speaking of healthcare being dumb, I’m going to be a little crass and direct you guys to my brilliant friend’s new healthcare and public policy blog.

Because as much as I’m excising my irritation with The Man / The System by complaining about the problems, Mark’s actually working on current efforts to solve them.

And you know, someone has to.

You could cut the irony with a knife

I’ve been off my Lexapro for a month and it turns out that’s bad.

Sometimes my patients have crippling anxiety.

When they do, I’ll take a few minutes to rule out other causes, report it to my preceptor, and they’ll breezily tell me “Fine – write a prescription for Zoloft, Lexapro, or Prozac – whatever you feel comfortable with. Do you know the dosing?”

Lady, you have no idea. By the way, I would also like a refill for myself.

… but for the life of me, I can’t find someone to take 10 seconds to write one for me.

I don’t feel it’s alarmist to say this is a problem.

I’ve been pretty open about my anxiety / depression. It’s been a non-issue for the last 4 years because my med school had outside psychiatrists.

But I’m not in med school anymore, and there are only a certain number of times you can refill a prescription from out-of-state without a visit – and I’ve gone way beyond that.

So now what?

I could set up an appointment at my current hospital, but I have to do a psychiatry rotation with these same attendings, so that seems… short-sighted.

I could call around at one of the competitor hospitals, but they’re all far enough away that I’d have to ask off work for “medical reasons”, which is a bit of a death knell. And why would they even accept our health insurance?

They probably don’t.

(Or maybe that’s just me making lame excuses? I honestly don’t know. My anxiety has ramped up to the point where the thought of just finding a phone number and calling someone is so mentally and emotionally exhausting that it’s impossible to tell.)

The thing that kills me (and the reason I’m writing this blog post at all) is that I know I’m not the only resident with this problem. I can’t be. Depression and anxiety are way too common – and the 80-hour work week and infeasibility of accessing your own hospital’s psychiatrists have to make this a global problem.

In the mean-time, there I am: taking a total of 10 seconds to jot down a prescription, then sitting in the corner anxiously twirling my pen and grinding my teeth.

Medicine sure can be stupid.

I mean, I celebrated last week because I got an article accepted to Gomerblog

You know how there’s a lot of German words for complicated emotions?

  • Schadenfreude: The pleasure you feel at someone else’s pain.
  • Schleppen: The labor at carrying a heavy object a very long way.
  • WanderlustAn impulse, longing or urge to go for long walks or hikes, or to travel
  • Zugzwang: A situation in which you have to make a move, but any move you make will be disadvantageous to you, whereas if you did not have to move, you would not be at a disadvantage.
  • WeltschmerzSentimental pessimism or melancholy over the state of the world

Do you know if there’s a German word for the emotion “my peer just had a 1st author paper accepted for publication to Cell and I’m simultaneously incredibly proud but also – good god, I need to seriously re-evaluate my suddenly wanting life?”

… asking for, um, a friend.

Edit: 15 minutes after posting this, one of my friends got a write-up in the New York Times. I’m officially having a small but incredibly selfish and confusing personal crisis.