Differences Between Pediatrics and Adults

I am making a comprehensive list of excuses perfectly good reasons for why I, a senior pediatric resident (fearless leader of interns! attending in the making! resident of the month x 3! winner of a multitude of teaching awards given by med students!) – make a terrible adult neurology intern.

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1: Adults with normal potasasium.. need more potassium. In peds, we are pretty much cool with anything over 3.2, and super scared of any number that starts with 5.

So in adult medicine this year, it wasn’t until the 3rd time I got a sign-out of “His K was 3.6, so we repleted IV” and reacted incredulously and indignantly before I finally accepted the truth of the new world order of adult medicine that I now must live by: K under 4.0 is unacceptable. Cardiac arrhythmias and whatnot. Asymptomatic PVCs.

are-we-gladiators-or-are-we-bitches

Be a man. Replete that shit.

2: Adults can sign-out AMA. My first AMA, I paged psychiatry to ask whether they thought the patient had capacity. I think the psych resident showed up more for moral support and genuine concern for me than anything else. Especially since I explained over the phone that I am from pediatrics and am scared to death to discharge a patient who needs more treatment.

They patiently explained that I am a doctor and can decide these things for myself. In turn, I patiently explained to them that I am basically dumb.

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3: Adult attendings are so hands-off you don’t even have to staff all in-house consults with them. You don’t even have to staff ADMISSIONS with them. In pediatrics, we don’t even page the resident first for consults – you page the attending, and they page the pediatric resident to say “Hey, go see this consult for me and then we’ll discuss it.” And at my program, even a 4am admision is paged to the attending first.

But in adult neurology subspecialties, it’s more like: Neurosurgery or the ED pages me out of concern for status epilepticus, I load the patient with whatever AED I want, I admit them if I want, and as long as the first thing I do works the attending doesn’t need to hear about it until rounds in the morning.

use-your-brain

Discovering this was… slow and painful. It involved an embarrassing number of incredulous conversations between me and an attending at 11pm.

4: Adults get lidocaine before you stab them in the back with a 22gauge needle. In pediatrics, we gave topical lidocaine, for all the good (NONE) that it did the patients. But if you turn 18 and get admitted to the adult unit – then you get SQ lidocaine and are not tortured.

… unless you happen to get a pediatric neurology resident as your LP-er. Then you get someone who has never given SQ lidocaine before and is not even aware that it is important.

5: Pediatric neurology residents are terrible people. As evidenced by the fact that there are 6 more of them in my program, and not a single one warned me of any of the above facts.

I distinctly remember the guy above me saying, and I quote: “Why are you so worried? Calm down. It’s gonna be fine.”

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Listen up, Mr. PGY-4:

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This post is for you.

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My First Week of Adult Neurology

Monday:

Attending: So! Dr Action Potential, what AED would you like to initiate?

Me: Keppra.

Attending: Correct. And why?

Me: Because… because the answer is always Keppra.

Attending: Correct.

Wednesday:

Attending: So we all agree that the patient’s seizures are not well-controlled on Keppra. Dr Action Potential, what is at the top of your differential diagnosis?

Me: … not enough Keppra.

Attending: Interesting! So what would be your recommended course of action?

Me: … give more Keppra.

Attending: Correct.

Friday:

 

Attending: Aha! You see, in THIS patient, we find ourselves confronting a new clinical conundrum, do we not? End-stage renal failure! Dr Action Potential, why is that a problem for our team?

Me: When the patient is in renal failure, one generally tries to avoid renally-excreted AEDs.

Attending: Correct. Clinical neurology is variable and exciting. Dr Action Potential, dare I ask, what antiepileptic would you recommend for this renal-failure patient?

Me: …the type of… Keppra… which is… renally-dosed.

Med Students: …

Attending: Correct. You know, if you didn’t tell me you spent the last 2 years in Pediatrics, I never would have guessed it. You’ve got this adult neurology thing in the bag.

Me: … Thank you, sir.

Attending: It’s quite remarkable.

Me: … I try, sir.

Things I learned in Pediatrics (Now that I’m done forever)

The family rarely needs you to be their friend. As a general rule, the family has a lot of friends. What they really need is someone who looks grave and important, who looks like they know what they’re doing, right there at the bedside, telling them exactly what’s wrong and what is going to happen.

I mean, it doesn’t hurt to be a nice person. That’s great as long as everything’s going according to plan and the patient isn’t actually sick. Your intern can be the nice person. But the most important thing I learned in residency is that when shit goes down, all anybody wants for their loved one is a genuinely serious-looking, order-giving, no-shit-taking, Doctor standing right. there.

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Sure, you can be nice and also in-charge. But if you’re walking into a room for the first time, the family usually feels better seeing someone who’s in-charge and also nice. It’s a crucial distinction.

You shouldn’t be the first one to say the word “dying” to the family. But you should damned well be the first person to write “dying” in your note. It’s a strong word. Your attending has the option to cross out this note in their addendum, but odds are you’re right, and they won’t. If you really believe it and none of the other teams have had the guts to write it, but everyone’s saying it – this is a good first step when you feel powerless.

Fellows have no power if they’re wrong. Call them on it. Useless as an intern, but good to remember past a certain point in PGY-2 when you’re fully aware that they are full of shit and you are graduating.

leaving

Enjoy the seniority while you can. Because in just 9 short work days, you will be back to the bottom of the barrel.

Welcome to fellowship.

i really want to have fun today because tomorrow is going to be a nightmare

10 Things Med Students Shouldn’t Do

This is my first year of being a senior resident and it is only January; and yet I have seen all these things happen.

Sadly, this has all led me to the grim realization of why I got such good evals as a medical student: it wasn’t because I was some sort of social genius. (And yes, I really thought I might have been a social genius.) No, it was because I did not do the following things, ALL OF WHICH I HAVE SEEN WITH MY OWN EYES.

Seriously, if you don’t do these things, don’t worry. You will be fine. Your residents will love you.

  • Do not claim to be late to rounds because you had a “Cat medical emergency last night.” Unless your cat is dead. But even then…. maybe don’t use the phrase “cat medical emergency”.
  • Certainly do not voluntarily (and eagerly!) disclose that your “Cat medical emergency” consisted of “I thought my cat was constipated but he wasn’t.”

huh2

  • DEFINITELY do not follow that up with “So the vet prescribed him kitty prozac. And I couldn’t sleep because I was so worried about the side-effects of the kitty prozac, so I was late.” Believe you me, I would rather you had just overslept.
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No judgement for ‘kitty death’. Lots of judgement for ‘r/o kitty constipation.’

  • Do not respond to the attending’s hopeful query “So, are you interested in [our specialty]?” with “Eeeeehhhhhh…
  • If a 4 month old is mildly tachycardic, do not suggest obtaining orthostatic vitals.
  • When a patient is admitted with, say, an asthma exacerbation – and you have happened to read in a past note that they are undergoing long-term therapy for PTSD- it is probably unnecessary and ill-thought out to open with “Hi! I’m a med student! So… it sounds like you were raped? Like, last year I think the chart says? How is that going?”

uh no

 

  • If I go through your patient presentation with you twice before rounds, in the most open, non-judgemental of ways, asking you repeatedly ‘Any other questions?’ – it is in the foolishly earnest hope that in front of the attending the words “So.. they were born at 38 weeks… is that preterm? Sorry, haha, I don’t know what preterm is” will NOT come out of your mouth.

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  • I will point out to you that the healthy teenager with the urine output of “0.3 cc/kg/hr” is likely not saving their urine. This is a gift. I do this to HELP you. I do NOT do this so that you can present the patient to the attending as “Initially, we were worried about kidney failure. After a lot of thinking about it, we  discovered that the patient was not saving their urine. Doing this led us to rule-out kidney failure, which we were initially very worried about, as I said.” (WHO IS WE. I DON’T EVEN KNOW YOU.)
  • Do not demonstrate “Suprapubic tenderness” by helpfully palpating my uterus.
  • Seriously, just… hands off your senior resident’s uterus.

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Thoughts From The NICU, PICU, and Nephrology:

  • The parking garage elevator at 6:05am is a comforting Who’s Who of other residents who don’t have their shit together.
  • Strive to write the kind of H&P that, years from now, will still be worth blatantly copying.
  • The NICU is the perfect place for people who want to spend their day doing only 1 thing really well. The PICU is the perfect place for people who want to spend their day bitching about the ineptitude of the floor teams.
  • The secret to a successful intubation: More anterior than that. Keep going. Keep going. Goddamnit, AS ANTERIOR AS HUMANLY POSSIBLE. There.
  • “So, wie es ist, bleibt es nicht” – Brecht
  • A good way to teach 4th year medical students without boring powerpoints is to teach them how to write orders.
  • Nobody is allowed to die without steroids.
  • Do not mess with: the pancreas. a cardiac baby. a grown woman’s precedex drip.
  • Just because you can rap the phrase “We think she’s hypertensive ’cause she’s volume-overloaded” does not mean anyone else will appreciate it.
  • Bad things happen when sodium runs amok.
  • Q4h labs will ruin your night shift.

“and oftentimes I am awoken at three in the morning by screams in the attic I’ll run upstairs, wrench the door open call out a warning (and try not to sound panicked) but my hammering heart hears the voices of spirits that tempt us, the scorn that they’ve spoken I’ll remember the sad frightened noises of an old friend who dreamt once of storms on the ocean

and black eyes looking up from below”

File Under “Med School Never Taught Me This”

So I’m getting an admit with a complicated history, right? One of those “__ year old male with h/o X, Y, and Z now s/p M complicated by A, B, and C with resulting D requiring M which is now s/p revision of X with resulting D who is now presenting with chief complaint of C ” patients.

Anyway, so that was fine. I have clinical skills. First things first – I carefully considered the most likely causes of C based on my extensive education in pathophysiology and instinctively deduced AHAHAHAHAHA aaaaah, haha nope.

sorry, can’t take myself seriously there.

Yeah, no, first things first – I looked up the most recent H&P in the EMR for reasons of borderline intellectual plagiarism.

As one does.

And do you know what I found, dear readers?

I found the following H&P, written by one of our illustrious fellows:

An H&P for this patient has been completed within the last 30 days. It has been reviewed and the patient has been examined with the following changes to the patient’s condition and exam: There are no changes in the patient’s condition or exam.

– Fellow McFellowton, MD

Followed by.. nothing. That was it.

That was the H&P.

infuriated silently

Absolute shoddiness. That fellow should be ashamed of himself.

(… small side-note: also, why can’t we do that? I DEMAND THE RIGHT TO BE SHODDY.

NO ONE EVER TOLD ME SHODDINESS WAS AN OPTION IN <30 DAY BOUNCE BACKS.)

i feel like i can't say anything and you can say everything

No. This will not stand. So I’m just gonna write

“An H&P has been completed for this patient within the last 30 days. It has been reviewed and the patient has been examined. There are no changes with the exception that this time the chief complaint is diarrhea, but otherwise, you know, samesies.

– Action Potential, MD”

I predict it will go… well.

The NICU: My Own Personal Hell Is Repetitively Stabbing Babies.

It’s sort of the exact opposite reason of why I went into pediatrics in the first place. Because I like babies, damnit.

I especially like babies who keep their blood inside their bodies.

… unless I need said blood, in which case I like just clicking on a “lab draw” order, pretending the Magical Blood Fairy shows up and waves a magic wand, and – poof! – the results magically pop up in the EMR.

But my faith has been shaken: it’s hard to believe in the Magical Blood Fairy when you’re staring at your hand holding a needle the size of an invisible artery.

It’s almost as hard as then actually managing to draw blood out of said invisible artery.

this isn't working is it

no but i liked that you tried and that you know when to give up

My attendings are undeservedly optimistic.

Last week, my attending pulled me aside after rounds.

“Listen, I just want to tell you that you’re doing an AMAZING job. Maybe the best intern we’ve had all year. Really super job.”

“Oh, thanks.”

So that was clear: she was about to compliment-sandwich me.

I hate compliment-sandwiches.

“But… “

There it is.

“It seems you haven’t gotten an arterial stick yet.”

“Yeah, no…  I haven’t.”

“You have to have 3 arterial sticks as an intern, you know.”

“Sure, I mean – I’ve tried – a lot! – but I just.. I haven’t had any luck. Or maybe I’m not a procedural kind of person?”

I was hoping she’d nod and agree.

In the subspecialty I’m going into, I will not have to do art sticks.

It is inhumane to babies for me to continue to try.

These are all good reasons for her to agree I should just stop.

“Wrong answer. You’re going to get an art-stick this week.”

Damnit.

“You look like you don’t believe me. I really want you to believe me.”

“Ok. I’m… going to get an art-stick this week.”

“Good! Don’t worry, everybody goes through this. Once you get one, they’re ridiculously easy. This will be your week!”

It was not.

Every single new admit, the attending would give me an exaggerated head nod which was my cue to grab everything I needed, confirm collateral circulation, sterilize the wrist, expertly poke the baby… and…

nbme

… usually create a hematoma.

when you make a mistake

After so many failed attempts, I just don’t know what to tell my attending.

I can’t really say “I think the babies are going to unionize and file a formal complaint against me.”

I also can’t say “I know you really want me to get this. But I think I’m causing more harm than good. If you could just stop thinking of me as a competent person, I think every baby in the NICU would be happier.”

I mean, she’s trying really hard. She’s the kind of attending most residents can only dream of! She really wants me to have this magical experience where I get the ABG and then turn into an awesome medical resident who can do procedures.

She would be so goddamned happy if I could just STICK THE NEEDLE WHERE IT BELONGS.

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But no matter how hard I try, the evidence is against me: I seem to be the kind of less-awesome medical resident whose days largely consist of me antagonizing innocent newborn babies with sharp instruments that I am in no way competent at wielding.

… So, right: +10 points for efficiency, minus several billion for the growing daunting weight of the knowledge that I will be going to hell.

… perhaps we’ll call it a wash.

My Old Nemesis, The NICU: Part III

“Hi. I’m the new very, very late intern. Where should I be?”

I just didn’t want to get yelled at. I knew I could make it through the day if the attendings and NPs were just politely irritated with me, but if I got outright YELLED at I’d definitely start crying -, and if there’s one thing I’ve learned neonatologists have in common with surgeons, it’s absolutely zero tolerance for clinician breakdowns.

So that was going to be my order of priorities:

  • #1, Absolutely no crying, and
  • #2 demonstrate that, on the plus side, I’ve already had the month of hell that is NICU as an MS-4 and I at least know the relevant math and fancy acronyms and therefore am not too much of a burden and perhaps might even (hope to god) be useful.

It was go-time.

I had thrown on my scrubs while calling the chief resident (who, upon learning that I was not in fact actually dead, seemed just as disappointed as I was about it. Can’t blame him for that one: there’s probably a set protocol for dead interns. It must be less clear how to manage the dumb oversleeping ones.)

After almost locking the door behind me, I suddenly realized what I needed, and took 20 seconds to run back into the house just to grab a pair of thick, horn-rimmed glasses.

No, I don’t need glasses. I never wear them.

But if there’s one thing I learned from TV it’s this: Nobody yells at the girl with thick glasses. They just vastly over-estimate her IQ and general reliability.

Yes, it’s dumb, but that kind of over-estimation was just what I needed to pin my hopes on in order to not just succumb to my innate desire to write off the entire month and possibly also drive off a cliff.

The difference between

The difference between “Aw, poor girl – that’s a rough start to the rotation” vs “Irresponsible and needs YELLING.”

It might sound dishonest, but I was honest where it counted: when the unit secretary pointed me toward the neonatologists, I walked up and told them straight-up “Hi, I’m Action Potential, I have no excuse. I slept through my alarm. I know it’s inexcusable. What should I get started with?”

Apparently the answer was an ABG, a central line, and pre-rounding on 4 patients in the 30 minutes I had before rounds.

BUT! No yelling!

… Yay?

So, had I been allowed to do ABGs and central lines in medical school, we would be back in the territory of things I could conceivably do.

But I wasn’t.

So we weren’t.

neverbeaherolucy

On the bright side: I prerounded on everyone and managed to come up with plans that made some clinical sense and just generally didn’t suck.

On the shadier side: ABGs and central lines on infants weighing less than a kilo… whose parents trust you because you are wearing a long white coat and introduce yourself as a doctor before torturing their tiny, innocent baby in the name of “practice”…

The NICU and I just don’t get along.

I am beginning to think we never will.