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.

 

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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.

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*

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 admitted 10 patients last night

Back in med school, I wondered how the interns wrote so many notes so quickly. It took me hours to do a good H&P, and in the process of writing it I would always remember something I forgot to ask or elicit.

Luckily, I’m now an intern, so I know the secret to writing lots of notes quickly:

Intern notes suck.

Even the best notes are only technically ‘good’ because we spent a couple extra minutes synthesizing the assessment and plan. Because, hey – the bright side to notes that suck is that nobody’s going to read a 3 paragraph HPI or a 4 paragraph history of someone’s back pain, and everyone’s just skimming your ROS and examination anyway, so what the hell, it’s okay that your family history consisted of two words.

(I used to bold the pertinent positives and negatives of the ROS and exam, but then one of my preceptors told me to knock it off because she likes to use bold for her own addendum. Which, okay, fine – I guess this way, at least no one will notice I didn’t check for cervical adenopathy in the kid with mono.)

The downside to notes that suck is that your original note will be repeatedly quoted in every consultant and social worker’s HPI, word-for-sucky-word.

I really can’t get over the fact that people actually read my notes now. (Or at least, copy and paste them). After 4 years of medical school, having a consultant specifically reference aspects of my HPI or assessment feels… wrong. And guilt-inducing.

Don’t you want to do your own assessment? Are you sure you want to rely on mine? I wrote this H&P in-between a rapid response, 3 “urgent” pages, the surgical fellow tapping his foot impatiently at the door, and sign-out.

But anyway, there you go: It used to take me 4 hours to write my weekly H&P, which would inevitably get ripped apart by the preceptor for not including tactile fremitus, CVA tenderness, a gait exam, and fifty additional ROS questions. This H&P would never, ever be read, because I was an M2.

Now I can write 10 H&Ps in a night, all of which will be quoted extensively by consultants who are relieved they don’t have to take the history themselves!

Something, something… patient safety.

I Ordered A Blood Transfusion Today

I’m not comfortable with the fact that this was, somehow, allowed.

And blood transfusions are really the WORST example, because there’s so many safety checks between the blood bank and the nurses – but even so, the fact remains: I have waaay too much responsibility.

And it’s not the “so many things I have to do!” kind of responsibility – it’s the “so many things for which I am legally and morally culpable!” kind of responsibility. And I am not used to that.

Med school does not prepare you for that.

Today I carried the other intern’s patients, because she had continuity clinic. And I got a page about a patient with, say, pancreatitis. “Still in pain after I gave tylenol dose. Can you put in an order for motrin?”

… Can I?

Sure, I checked up on the patient first. But even after that, it took me at least 5 minutes of research to feel confident that motrin was definitely okay in pancreatitis. (Why wouldn’t it be? Shit, I don’t know. Stomach ulcers? I just had a general feeling of unease about it).

Then it took me 10 more minutes to figure out how to prescribe it, because of finicky things with dosing and formulations. And then I was unsure if I maybe overprescribed it, so I had to call the pharmacy to double-check.

The nurse was not amused by the delay.

So yes, you could say intern year is going great.

I got another page today: “Patient ‘TotallyStable McHomeSoon’ is desatting to high 80s on blow-by, sBPs in 80s. Please come to bedside to assess.”

So I jogged over, assessed, gave a few obvious orders (Nasal canula, 1 L. …. Nasal canula, 2L… albuterol on stand-by…), came up with a reasonable assessment and plan, and left the nurse at the bedside so I could quickly update my senior resident.

I figured she’d probably be okay with my management, but might be deservedly annoyed I didn’t inform her sooner. I mean, this kid was initially unstable.

But she just said “Right, I heard about that patient’s desats,” – and with great restraint and calculated patience, she continued: “They told me first. So I told the nurse to page you.”

Which… what? Excuse me?

WHY WOULD YOU DO THAT.

So I went back in the room, kept managing him – and the patient turned out fine (eventually stable on room air) – but I do not like that kind of pressure.

Even worse, one of the things on my differential was that I had recently reconciled all of his many, many medications – and some weren’t on formulary, so I had to call the pharmacist – and… maybe I made a mistake? Maybe this was pharmacologic respiratory depression? He had just gotten his morning medications, after all.

So for at least 5 minutes, I was seriously considering the fact that I might have made an inadvertent error that could have seriously hurt someone.

I didn’t. Turns out it was something else entirely – but… the bright feeling of “Whew, I didn’t make a mistake!” is being tempered by this inner voice that’s adding “This time” to the end of that sentence.

Why would anyone WANT this kind of pressure? Who the hell decides to be a doctor? Who wants to reconcile outside medications, knowing that there’s a chance you’ll make a minor error, and see a patient in acute respiratory distress?

(Again: I was not the cause. I reconciled perfectly.)

(… this time.)

We had a code today, too. I was ecstatic that – despite being disturbingly close by when the code was called / the alarms went off – I still somehow managed to be too late to be of any use. (YES! The holy grail: responding emergently like a responsible person, and not being needed.)

Still, I stuck around with about 10 other residents / attendings / nurses in case they had to go to chest compressions and needed the extra help.

Chest compressions, I can do.

This day-to-day “ordering potentially life-threatening medications under my god-given name” thing? That’s much harder.

Sign-out really needs to happen more than once a day

Our attending’s goal is to make rounds fly by as quickly as possible, with a bare minimum of any actual HPI or physical exam findings.

Our Sub-I’s goal is manage their patients by themselves, as an actual practice for residency.

Our senior resident’s goal is to discharge / transfer people out as quickly as possible, because she has one foot out the door.

And the night intern just wants to get a sign-out from us that doesn’t suck and addresses all their questions so they can take care of like a million kids.

I get up early every morning to review the list of kids on the ward (all of them, not just the ones I’m assigned) because I hate getting called to the bedside of a kid I don’t know. (Rounds are supposed to mitigate this kind of thing, but we go so fast – and our turnover is so high with all the discharges, that it usually doesn’t help.)

Yep, I’m the intern. Nope, nobody told me that this patient even existed. No, I can’t believe it either. The lack of communication here is stupid, dangerous, and totally unnecessary.” <– is what I don’t say. But it’s true.

The sign-out list I’ve been carting around is now no longer relevant and so I page the senior. Maybe she gave the patient to one of the Sub-Is? Maybe she’s been managing that patient herself because she wanted me to finish discharging my other kids? Maybe a ghost put in the admit orders?

So I show up to the nurse’s call, make sure the kid isn’t actually coding, make a couple minor interventions to bide some time (Let’s stop the feeds and try some blow-by even though I don’t know the patient’s history!) and page the senior.

Today the medical students looks at me sadly like, “You couldn’t even handle that yourself?”

Nope.

You could actually see the respect draining out of their eyes.