I'm just not having much success at coming up with new reflections. I opened the blog to try to write one last night but finally gave up. I guess tonight I just want to spend a little time talking about something that came up at work today. I was talking with one particularly distraught mom. Her very young (weeks old) daughter was being worked up to rule out sepsis (bloodstream infection with additional features), and it had been a nightmarish day. In addition to the various normal blood tests required, a lumbar puncture (aka spinal tap) is necessary for the workup, so between all the testing and the fact that her daughter was in the emergency room and simply waiting for a bed to be ready before being admitted to the hospital, mom was pretty much beside herself. And the worst of it, she acknowledged, was the sense of helplessness, the realization that she couldn't do anything to make this better for her baby. And she had no choice but to accept that; there were really no alternatives.
I think most of us feel helpless from time to time, if not more frequently. We see things playing out, we see how much pain certain events are causing, but we are powerless to stop or alter them. Sometimes we try anyway, knowing that we will fail, knowing that we'll probably do more harm than good, simply because we cannot bear to feel helpless. But I also think that Lent is about an example of helplessness that became the basis for human salvation. If He chose to become helpless on the cross for our sake...maybe there's a lesson for us there? Just a thought.
Anyway, that's all for me tonight. Hope everyone's doing well...till next time, peace and God bless!
Showing posts with label pediatric emergency medicine. Show all posts
Showing posts with label pediatric emergency medicine. Show all posts
Wednesday, March 30, 2011
Monday, October 11, 2010
A little behind
Whoops...I've been slacking just a little recently. So now might be a good time to make up for that a bit and write about one of the more interesting kids I've seen over the last couple of days. The patient I remember most vividly was a teenage girl who came in complaining of abdominal pain in the right lower quadrant. She and mom were particularly concerned about appendicitis, and with some reason. The onset of the pain had been rapid and severe, and it had kept her from wanting to eat or drink anything. It was worse with moving around, and had been excruciating when they had hit bumps on the way in. But she didn't have any fever, her appetite was starting to return, and her pain was improving as time went on (very rare with appendicitis). We still wanted to try to rule it out, so we ordered a CBC and an abdominal / pelvic ultrasound. The CBC came back stone-cold normal with maybe a little left shift. Probably not appendicitis, we thought then, so what could it be? Our temporary theory was an ovarian cyst -- many of the symptoms overlap. When the ultrasound came back, we found out we were half right -- the ovary was involved. Instead of a cyst, however, there was a solid mass of unknown origin. When we broke this news, both patient and mom were pretty upset. After all, when you tell someone about a "mass," the first thing they'll think is "tumor." The only comfort we could offer at the time was that it was very unlikely to be cancer given her age and background. The radiologists backed us up on that -- we had ordered a CT scan at the behest of pediatric surgery, and it was read as showing an adnexal mass, probably benign. So at the tail end of my shift (by which I mean two hours after I was scheduled to leave, but worth every minute), we went back to tell her this as well as let her know that surgery would be down to see her. I guessed that since she was feeling much better they would probably decide to send her home and have her follow up as an outpatient. When I went back in the following day, I had a rare moment of down time which I used to check and see what had ended up happening. Peds surg had, in fact, evaluated her and decided to take her to the OR, where they had discovered a ruptured ovarian cyst and a medium-sized benign-looking mass that they had sent for biopsy (results on that were still pending...I should check and see if that was ever completed). It was a bit of a zebra, definitely not a common pathology, but we had managed to come up with a (mostly) correct diagnosis and now it sounds like the problem should be permanently taken care of.
Sorry, bit of a long story there, but definitely a good case (especially since she had a good outcome) and one I was glad to be a part of. And that's true so often in the emergency department -- it's nearly always a blessing, one way or another, to be involved. Some cases are tragic (for example, the 10 month old with a depressed skull fracture and massive subdural bleed that were 100% non-accidental; even if she survives she'll likely be neurologically devastated), but it's still a privilege (not to mention a valuable learning experience) to be involved. Every day, unless you actively avoid doing anything, you'll be making a difference in someone's life, and occasionally, that difference is profound (sometimes even the difference between life and death). You get to make kids' lives better, to watch them heal right in front of your eyes. They come in sick or broken and they leave healthy and whole. It's a feeling unlike any other in any job one could possibly imagine.
Anyway, that's all for tonight...I'm exhausted. I likely won't be posting tomorrow (I'm working 5P-1A) unless I actually get home reasonably close to 1 (it normally seems to be closer to 3 or 3:30), and I'm working the same shift on Wednesday, so unless I get some unexpected free time, it may be a couple of days before I'm posting again. But I'll be back. Till then, peace and God bless!
Sorry, bit of a long story there, but definitely a good case (especially since she had a good outcome) and one I was glad to be a part of. And that's true so often in the emergency department -- it's nearly always a blessing, one way or another, to be involved. Some cases are tragic (for example, the 10 month old with a depressed skull fracture and massive subdural bleed that were 100% non-accidental; even if she survives she'll likely be neurologically devastated), but it's still a privilege (not to mention a valuable learning experience) to be involved. Every day, unless you actively avoid doing anything, you'll be making a difference in someone's life, and occasionally, that difference is profound (sometimes even the difference between life and death). You get to make kids' lives better, to watch them heal right in front of your eyes. They come in sick or broken and they leave healthy and whole. It's a feeling unlike any other in any job one could possibly imagine.
Anyway, that's all for tonight...I'm exhausted. I likely won't be posting tomorrow (I'm working 5P-1A) unless I actually get home reasonably close to 1 (it normally seems to be closer to 3 or 3:30), and I'm working the same shift on Wednesday, so unless I get some unexpected free time, it may be a couple of days before I'm posting again. But I'll be back. Till then, peace and God bless!
Wednesday, October 6, 2010
8-6 in the ED
I was on the 8-6 shift today and ended up working till about 7:15, and while every minute was worth it, it's left me with very little gas in the tank...and I'm working the same shift tomorrow, so some sleep is probably in order. Sleepy as I am, though, I have to say that this is by far the best rotation I've been through to this point. I love having as much responsibility as I do for taking care of patients and doing basically everything that needs to be done -- calling consults, looking at labs and images, reading previous records, and coming up with plans. It's expanded my comfort zone tremendously -- I'm willing to make the call on some things now. Granted, they're small things, but at the beginning of the rotation I'd have said "Hold on, let me ask the attending" rather than just saying "yeah, it's ok for him to eat" or "sure, since we're going to discharge her, you can pull the IV now." Every day I'm learning, not only how to diagnose and manage patients, but how to improve and exercise my medical judgment -- and I'm learning to trust that judgment.
Today's kids were a varied bunch. My first little guy came in struggling to breathe; once he got an albuterol nebulizer, he began to wheeze like crazy. He was working hard, retracting, flaring, and his lungs sounded like junk. He came in as a level 3 (moderate acuity) in orange pod; after a couple of hours with no improvement in his respiratory symptoms and deterioration of his general clinical picture, we sent him to the red (high acuity) team; they told me later on that he had ended up being admitted to PICU. Poor kid...I just hope he maintained sufficient respiratory function to avoid an ET tube. The second kid, a girl, came in with abdominal pain that she'd had for the last two weeks. Her story was kind of scary, involving intense, rapid-onset abdominal pain for several days that suddenly became much better; it stayed that way for a day and a half before the pain began to resurface. All the medical people reading this are now wondering if she had ruptured appendicitis -- but her exam was fine. Mild pain and tenderness in the right lower quadrant, but nothing serious, and no decreased appetite or anything like that. So we sent her for an x-ray. Final diagnosis? FOS -- Full Of Stool. Her colon was pretty backed up from the looks of things, so we gave her a decent-strength laxative and sent her home. Then there was the young lady who came in with abdominal pain for a month. I'd tell you her story except that after history, physical, and several tests, we're still no closer to figuring out what's going on. Almost as frustrating for me as for her. The only other interesting case of the day was an energetic little guy who looked absolutely peachy. Mom said he'd had an asthma attack yesterday and she had taken him to the doctor this morning; they did an exam and sent him over to Children's for a chest x-ray. I was frankly wondering what they were thinking. The kid was afebrile and looked like a million bucks. And then I listened to him. His right lung was ok, but his left lung had textbook crackles at the base. I mean, they were absolutely perfect, exactly like the sounds they record for the training videos and such. So we got that CXR, and sure enough, even though he didn't appear to be the least bit sick, it showed an apparent pneumonia (although the radiologist read it as a right lung PNA, which didn't correlate with the clinical findings -- looking at the film, though, I could see what they were looking at). So he came in for asthma and left with a 10 day prescription for antibiotics. Also interesting was the fact that after he got a breathing treatment, his wheeze reappeared and his crackles became much more pronounced. He still looked great, though, and we ended up discharging him with his meds. (I saw two other patients as well, but there wasn't really anything interesting about either of them).
So yeah, that was the day. I think I still owe a description of Monday; hopefully I'll get to that at some point. In the meantime, though, I'm going to bed, so until next time, peace and God bless!
Today's kids were a varied bunch. My first little guy came in struggling to breathe; once he got an albuterol nebulizer, he began to wheeze like crazy. He was working hard, retracting, flaring, and his lungs sounded like junk. He came in as a level 3 (moderate acuity) in orange pod; after a couple of hours with no improvement in his respiratory symptoms and deterioration of his general clinical picture, we sent him to the red (high acuity) team; they told me later on that he had ended up being admitted to PICU. Poor kid...I just hope he maintained sufficient respiratory function to avoid an ET tube. The second kid, a girl, came in with abdominal pain that she'd had for the last two weeks. Her story was kind of scary, involving intense, rapid-onset abdominal pain for several days that suddenly became much better; it stayed that way for a day and a half before the pain began to resurface. All the medical people reading this are now wondering if she had ruptured appendicitis -- but her exam was fine. Mild pain and tenderness in the right lower quadrant, but nothing serious, and no decreased appetite or anything like that. So we sent her for an x-ray. Final diagnosis? FOS -- Full Of Stool. Her colon was pretty backed up from the looks of things, so we gave her a decent-strength laxative and sent her home. Then there was the young lady who came in with abdominal pain for a month. I'd tell you her story except that after history, physical, and several tests, we're still no closer to figuring out what's going on. Almost as frustrating for me as for her. The only other interesting case of the day was an energetic little guy who looked absolutely peachy. Mom said he'd had an asthma attack yesterday and she had taken him to the doctor this morning; they did an exam and sent him over to Children's for a chest x-ray. I was frankly wondering what they were thinking. The kid was afebrile and looked like a million bucks. And then I listened to him. His right lung was ok, but his left lung had textbook crackles at the base. I mean, they were absolutely perfect, exactly like the sounds they record for the training videos and such. So we got that CXR, and sure enough, even though he didn't appear to be the least bit sick, it showed an apparent pneumonia (although the radiologist read it as a right lung PNA, which didn't correlate with the clinical findings -- looking at the film, though, I could see what they were looking at). So he came in for asthma and left with a 10 day prescription for antibiotics. Also interesting was the fact that after he got a breathing treatment, his wheeze reappeared and his crackles became much more pronounced. He still looked great, though, and we ended up discharging him with his meds. (I saw two other patients as well, but there wasn't really anything interesting about either of them).
So yeah, that was the day. I think I still owe a description of Monday; hopefully I'll get to that at some point. In the meantime, though, I'm going to bed, so until next time, peace and God bless!
Monday, October 4, 2010
Quick update
Just a quick update from my Saturday night shift since I'm working again tonight and need to take a nap. Weekend night shifts are invariably busy, and this one was no exception. It has to be a little tough on the attendings; there are three of them and probably ten or twelve students / mid-level providers / residents that they have to supervise and take report from, and they have to see all of the patients who come through. Boy do they keep busy...
Anyway, it was a fun night. I saw six patients, one of whom was signed out to me, one who I sort of stumbled into taking over from the previous shift, and four whom I picked up on my own. The ones I picked up included a young kid with a respiratory virus (admitted), a kid who'd swallowed a penny and had enough bad luck that it stuck in his esophagus (sent to the OR and discharged from PACU), a kid with a headache who'd fallen out of bed that morning whose mom was concerned that it was a head injury (examined and discharged), and a young kid with a 3 day history of fevers to 104 who looked happy as a clam (worked up for UTI and discharged; her parents were miffed about the wait but oh well). The other two patients...well, there's a story behind those, but I won't get into it now. Suffice it to say that I learned two things:
1) When you're leaving, sign out ALL your patients to the person relieving you; otherwise, when the attending asks me about the patient that you forgot to sign out to me, I will have no idea who or what she's talking about.
2) If you did a history and physical on a patient before signing him/her out to me, take ten minutes and write a note. Otherwise, when I go back at 2 in the morning, an hour after my shift was supposed to end, to addend the note with the radiology / lab findings and final disposition, I will look through the list of notes twice more after not seeing it the first time, shake my head in disbelief, mutter a string of curses (which I don't do often, just in case you're not aware), and ask the intern sitting next to me if she has any thoughts on how the handle the situation. It will ultimately result in there being ZERO documentation of any H&P on the patient, repeated comments in my note that I didn't do a history or physical because the patient was signed out to me, and a fuming blog post on the subject from an annoyed colleague (yes, that would be me). Ahem. Rant over.
Anyway, I'll try to give a few more details tomorrow, but if yesterday is any indication of how I'll be feeling, it might end up being postponed again. We'll see. Till next time, peace and God bless!
Anyway, it was a fun night. I saw six patients, one of whom was signed out to me, one who I sort of stumbled into taking over from the previous shift, and four whom I picked up on my own. The ones I picked up included a young kid with a respiratory virus (admitted), a kid who'd swallowed a penny and had enough bad luck that it stuck in his esophagus (sent to the OR and discharged from PACU), a kid with a headache who'd fallen out of bed that morning whose mom was concerned that it was a head injury (examined and discharged), and a young kid with a 3 day history of fevers to 104 who looked happy as a clam (worked up for UTI and discharged; her parents were miffed about the wait but oh well). The other two patients...well, there's a story behind those, but I won't get into it now. Suffice it to say that I learned two things:
1) When you're leaving, sign out ALL your patients to the person relieving you; otherwise, when the attending asks me about the patient that you forgot to sign out to me, I will have no idea who or what she's talking about.
2) If you did a history and physical on a patient before signing him/her out to me, take ten minutes and write a note. Otherwise, when I go back at 2 in the morning, an hour after my shift was supposed to end, to addend the note with the radiology / lab findings and final disposition, I will look through the list of notes twice more after not seeing it the first time, shake my head in disbelief, mutter a string of curses (which I don't do often, just in case you're not aware), and ask the intern sitting next to me if she has any thoughts on how the handle the situation. It will ultimately result in there being ZERO documentation of any H&P on the patient, repeated comments in my note that I didn't do a history or physical because the patient was signed out to me, and a fuming blog post on the subject from an annoyed colleague (yes, that would be me). Ahem. Rant over.
Anyway, I'll try to give a few more details tomorrow, but if yesterday is any indication of how I'll be feeling, it might end up being postponed again. We'll see. Till next time, peace and God bless!
Friday, October 1, 2010
Best job in the world
I can't get over the fact that eight or so years from now, someone will be paying me to do what I did today. As much as last month was a struggle, that's how much this month is a joy. You know you love what you do when you look forward to each of your shifts as much as you do to your days off.
Today was a pretty busy one. All told, I saw five patients, each with a different complaint and needing a different workup. That's one of the many benefits to the ED -- you'll see anything and everything. (Of course, at times I suppose that's also one of the drawbacks). I actually felt like I was holding my own with the junior residents today in terms of seeing patients, although I definitely need to learn how to take care of administrative tasks (consults, admissions, discharges) more efficiently. (It would probably help if I had a pickle phone, but who in their right mind gives a third-year medical student one of those?!) Regardless, though, I saw (and admitted) a patient with recurrent severe abdominal pain (also did my first guiac test for occult blood, but like all the other tests we did, it didn't really help us figure out what was going on), had another kid with a wrist injury after wrestling with his sister (x-rays were negative, so we splinted his wrist and sent him home with ortho follow-up), one girl who was less than 2 years old but had an extensive history of hospitalization for asthma (mom and dad had brought her in pre-emptively because they recognized the warning signs, and I think we cut off a more extended hospital stay at the pass), a little guy who had sat around in another ED for 6 hours before being transferred to CHP by ambulance (as soon as he got through our doors he perked up and looked great, so he got sent home after some IV fluids), and a kid whose PCP swore he had a dangerous complication of strep (he was reacting to a medication). If I wasn't in a patient's room, I was bugging GI (I talked with at least two fellows and one resident, possibly more), presenting to an attending, writing a note, or preparing discharge instructions. I was there a full hour and a half longer than my shift was supposed to run, but the entire day went by in a flash.
Still, though, as fun as this is, there's room for some serious improvement. I need to start thinking about management much earlier in the process so that I have something semi-intelligent to say when the attending asks "So what do you want to do for this kid?" I'd really, REALLY like to get the right answer to that question a few times before the rotation ends.
Anyway, that's all for now...tomorrow I work from 5 PM until 1 AM, and I strongly doubt I'll be in a fit state of mind to post immediately after that, so I'll write something on Sunday. Until then, peace and God bless!
Today was a pretty busy one. All told, I saw five patients, each with a different complaint and needing a different workup. That's one of the many benefits to the ED -- you'll see anything and everything. (Of course, at times I suppose that's also one of the drawbacks). I actually felt like I was holding my own with the junior residents today in terms of seeing patients, although I definitely need to learn how to take care of administrative tasks (consults, admissions, discharges) more efficiently. (It would probably help if I had a pickle phone, but who in their right mind gives a third-year medical student one of those?!) Regardless, though, I saw (and admitted) a patient with recurrent severe abdominal pain (also did my first guiac test for occult blood, but like all the other tests we did, it didn't really help us figure out what was going on), had another kid with a wrist injury after wrestling with his sister (x-rays were negative, so we splinted his wrist and sent him home with ortho follow-up), one girl who was less than 2 years old but had an extensive history of hospitalization for asthma (mom and dad had brought her in pre-emptively because they recognized the warning signs, and I think we cut off a more extended hospital stay at the pass), a little guy who had sat around in another ED for 6 hours before being transferred to CHP by ambulance (as soon as he got through our doors he perked up and looked great, so he got sent home after some IV fluids), and a kid whose PCP swore he had a dangerous complication of strep (he was reacting to a medication). If I wasn't in a patient's room, I was bugging GI (I talked with at least two fellows and one resident, possibly more), presenting to an attending, writing a note, or preparing discharge instructions. I was there a full hour and a half longer than my shift was supposed to run, but the entire day went by in a flash.
Still, though, as fun as this is, there's room for some serious improvement. I need to start thinking about management much earlier in the process so that I have something semi-intelligent to say when the attending asks "So what do you want to do for this kid?" I'd really, REALLY like to get the right answer to that question a few times before the rotation ends.
Anyway, that's all for now...tomorrow I work from 5 PM until 1 AM, and I strongly doubt I'll be in a fit state of mind to post immediately after that, so I'll write something on Sunday. Until then, peace and God bless!
Tuesday, September 28, 2010
Lessons learned
Ok, so for everything I did right today, I made at least two mistakes. I've definitely got a lot to learn. One of the things I learned today is that attendings are attendings for a reason, and when you disagree with them, prepare to be proved wrong. Twice today I was surprised by the conclusions and management plans of attending physicians, and both times it turned out that their "gut feeling" had caused them to interpret the evidence correctly (even though my explanations seemed more obvious). [Also I should point out that I wasn't stupid enough to SAY anything in either case...good thing, too.] First case was a little kid who had been in a couple of days ago after lacerating his eyelid with a colored pencil. He had a superficial lac and was sent home with some erythromycin ointment (that's an antibiotic for the non-medical folks keeping score at home). Today he came back because his eyelid was swollen shut. And I mean SHUT. It took four of us to hold the kid down that the resident could peel back his eyelid and the attending could get a quick look at his eye. Still, though, his eye was moving ok and didn't look super-bad, and when we weren't poking at him the kid was in a pretty good mood, so I figured the attending would give him a dose of IV antibiotics (probably clindamycin as the kid had a history of drug reactions to penicillins), observe him for a while, and probably send him home on PO ( = oral) antibiotics. Thus, I was fairly surprised when she said "You know, I wasn't able to get a great look at the eye, and I don't feel comfortable sending him home. I think we should get a CT of his orbit to make sure there's nothing going on there." I mean, it's a textbook superficial cellulitis, right? ...not so much. An hour later, I ran into the resident in the work station. "You're not gonna believe this," she says. She pulls up the CT, and there in the kid's orbit is a decent-sized lesion. Apparently some of the lead from the colored pencil had embedded itself in the orbit. Last I heard, he was scheduled to go to the OR with ophthalmology. Bit of a turnaround from wondering if we could send him home, and my first lesson on the ability of the attendings to integrate experience, "gut" instinct, and data to arrive at the proper course of action.
The second case involved a teenage girl with abdominal pain. A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis. After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative. So we were talking about ultrasounds and other testing for ovarian pathology and the like. I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid. She was back five minutes later. "I think this kid has appendicitis." Again, I was skeptical. Again, I was wrong. As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve. She began to display rebound tenderness and her white count was elevated. By the end of the day, it looked like pretty classic appendicitis. Attendings 2, SL 0. Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.
Still, though, despite my stumbling and bumbling, I had the time of my life today. I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully. It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance). I can't tell you how excited I am to go back tomorrow! This is going to be a great month, and I'll be looking forward to every single shift.
Anyway, that's all for now...back tomorrow with more tales from the ED. Till then, peace and God bless!
The second case involved a teenage girl with abdominal pain. A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis. After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative. So we were talking about ultrasounds and other testing for ovarian pathology and the like. I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid. She was back five minutes later. "I think this kid has appendicitis." Again, I was skeptical. Again, I was wrong. As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve. She began to display rebound tenderness and her white count was elevated. By the end of the day, it looked like pretty classic appendicitis. Attendings 2, SL 0. Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.
Still, though, despite my stumbling and bumbling, I had the time of my life today. I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully. It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance). I can't tell you how excited I am to go back tomorrow! This is going to be a great month, and I'll be looking forward to every single shift.
Anyway, that's all for now...back tomorrow with more tales from the ED. Till then, peace and God bless!
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