Death count for my PICU rotation: 4 and climbing...
Worst by far was the mother who found her 15 year old daughter down in her room. EMS resuscitated but her pupils became fixed during transport and she was brain dead by the time she got to the PICU. Her cerebral perfusion scan was eerie for the complete and total absence of all blood flow. It was like someone went in and performed a total lobectomy, the cutoff was so precise. Tox screen negative, all lab work negative, no signs of trauma, asphyxiation, etc. We have no idea why this perfectly healthy girl was suddenly found essentially dead.
There are true tragedies in this world.
July 24, 2009
July 22, 2009
Waste Management
There's a protocol around here 
for how you attack an infant with a fever of unknown source (FUS). Basically, the justification is that since babies can't tell you they're sick, and are at risk of serious infections, every one of them gets a full sepsis workup. Blood culture, urine culture, lumbar puncture, CSF culture, and a cherry on top - and then they get parked in the hospital while those cultures cook in the lab.
While I was on my general peds inpatient stint, we averaged around 5 of these a week; almost every day we have another "rule out sepsis" touchdown in our ward. They begin to blend together - a day or so history of fever, maybe some lethargy or poor feeding, occasionally some sniffles or a change in stool. The cultures always come back negative, of course, and if the bigwigs on Washington saw my life as a 30min episode of reality TV, they would be up in arms bemoaning the "Waste of healthcare dollars! Defensive medicine! Rabble rabble rabble!"
My last FUS was a little different, however. He also had the classic history - 2-3 day history of fever hovering around 101, not feeding as well, a little fussy. But mom didn't take him to the doctor. After all, its just a little temp. Babies get sick, it happens. Until she was holding him and watched his eyes roll back in his head as he stopped breathing and turned blue. EMS got him resuscitated, and that's when I met him in the PICU, after the damage had been done. That moment little baby turned blue, his body could no longer compensate from the bacteria and cytokine storm raging in his body. Brain MRI showed diffuse bilateral watershed infarcts; he was brain dead. Blood cultures taken in the ED grew gram negative bacteria.
That's the crazy thing about all this preventative medicine, rule out sepsis, empiric treatment mumbo jumbo. It lulls you into complacency until that moment it blindsides you. One of the classic lessons of medicine is "learning diligence"; to never settle with an innocent diagnosis until you have ruled out the dangerous ones. It's often a lesson learned the hard way. Would the money spent ruling out sepsis on that one kid have been worth all the money spent on the other kids ruling out sepsis? I bet you his mom would have said so.
The worst part of all about this case is that his blood ended up growing out Haemophilus influenzae type B. A bug he SHOULD have been vaccinated against. But mom was afraid of vaccines.
As one of the residents macabrely put it: "At least he never got autism."
You go Jenny McCarthy!
for how you attack an infant with a fever of unknown source (FUS). Basically, the justification is that since babies can't tell you they're sick, and are at risk of serious infections, every one of them gets a full sepsis workup. Blood culture, urine culture, lumbar puncture, CSF culture, and a cherry on top - and then they get parked in the hospital while those cultures cook in the lab.While I was on my general peds inpatient stint, we averaged around 5 of these a week; almost every day we have another "rule out sepsis" touchdown in our ward. They begin to blend together - a day or so history of fever, maybe some lethargy or poor feeding, occasionally some sniffles or a change in stool. The cultures always come back negative, of course, and if the bigwigs on Washington saw my life as a 30min episode of reality TV, they would be up in arms bemoaning the "Waste of healthcare dollars! Defensive medicine! Rabble rabble rabble!"
My last FUS was a little different, however. He also had the classic history - 2-3 day history of fever hovering around 101, not feeding as well, a little fussy. But mom didn't take him to the doctor. After all, its just a little temp. Babies get sick, it happens. Until she was holding him and watched his eyes roll back in his head as he stopped breathing and turned blue. EMS got him resuscitated, and that's when I met him in the PICU, after the damage had been done. That moment little baby turned blue, his body could no longer compensate from the bacteria and cytokine storm raging in his body. Brain MRI showed diffuse bilateral watershed infarcts; he was brain dead. Blood cultures taken in the ED grew gram negative bacteria.
That's the crazy thing about all this preventative medicine, rule out sepsis, empiric treatment mumbo jumbo. It lulls you into complacency until that moment it blindsides you. One of the classic lessons of medicine is "learning diligence"; to never settle with an innocent diagnosis until you have ruled out the dangerous ones. It's often a lesson learned the hard way. Would the money spent ruling out sepsis on that one kid have been worth all the money spent on the other kids ruling out sepsis? I bet you his mom would have said so.
The worst part of all about this case is that his blood ended up growing out Haemophilus influenzae type B. A bug he SHOULD have been vaccinated against. But mom was afraid of vaccines.
As one of the residents macabrely put it: "At least he never got autism."
You go Jenny McCarthy!
July 7, 2009
Balls.
So during our pre-clinical years we had this wonderful class called "Principles of Clinical Medicine" which was "designed" to impart onto us all the skills we need to survive in the clinical world that you don't learn out of a basic science textbook. 
We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)
Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer
Now that's real wards experience.
BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.
Cryptococcus!
(You might be a med student if you get that joke.)
We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer
Now that's real wards experience.
BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.
Cryptococcus!
(You might be a med student if you get that joke.)
July 6, 2009
The Big Leagues
I was a big baseball player growing up. T-ball, coach pitch, Little League, American League, all the way up through high school ball. The developmental leagues in the American ball system have a very specific method to their madness. Each level has its own set of skills it develops. T-ball is all about learning the rules of the game and the fundamentals - how to field a ball, how to throw a ball, etc. Little League is all about proper technique, learning how to turn a double play, who to hit as your relay man, and such. By college ball/minor leagues, the fundamentals are all supposed to be in place, and you focus on refining technique and maximizing talent. Then you reach the big leagues and its all about delivering on your talent.Academia is a similar sort of setup, especially when it comes to medicine. High school is your t-ball. Developing study skills, learning the fundamentals of each subject, starting on your critical reasoning. College is your little league. Experimenting how to efficiently learn, developing your reasoning and communication (and drinking) skills. The pre-clinical years of med school are the minors where you are working on adding the necessary information to your cranium to step up to the top level.
Lame analogy? Super lame. But the nickname around here for the clinical years is the "Big Leagues" and after a week of getting my feet wet I can see where it comes from. No more syllabus to hold your hand and feed your orange slices between innings. No more cute little "classic presentation" clinical vignettes to tell you to lower your elbow on your swing. Just you, the patient history, the physical exam, some lab tests, and a team of individuals grossly more experienced and knowledgeable than you waiting impatiently for your assessment and plan. It's terrifying but infinitely more fun.Anyways, enough melodramatics. I think the rub is that third year is an entirely different beast. Peds has been a great rotation to start on. By its very nature it tends to accumulate more nurturing personalities and its been a good atmosphere to hopelessly stumble around in during the first few days. From the intern to the attending, everyone has been great at understanding and helping me with my incompetence. Kids are definitely my fave patient population and we've had some real cute ones on the floor this past week. I'm glad my first H&P was with a mother concerned about her adorable little daughter instead who was previously healthy and not on a 47 year old chronic patient with a PMHx and a Meds list the size of the US deficit. So I'm having a blast so far. Some moments from my first week:
--10 year old little boy who presented with focal hemiparesis. Was originally given diagnosis of acute disseminated encephalomyelitis, until the CSF came back with oligoclonal bands and tests showed myelin basic protein antibodies. Diagnosis of Multiple Sclerosis, that was a real heartbreaker.
--Little 2 month old baby admitted with poor feeding and failure to thrive. MRI showed diffuse hypomyelination of the CNS. In medicine, generally the more names in a condition, the worse it is. Especially if they're German names. This baby was suspected of having a condition consisting of 3 German names. Such a bummer, and the worst part was that he was perfectly healthy at delivery and until 8 weeks of life.
--On call when the intern gets a page that a patient admitted the night before for UTI was "turning blue." We run down to the room and see a poor child who was inconsolable in her mothers arms, had just had an impressive bout of diarrhea, and who had purple extremities with cap refill of 4-5 sec. Luckily everything turned out alright and she was discharged today.
--The family practice intern walked in on two cystic fibrosis patients doing the horizontal handshake. Yes, we all know the hospital is a boring place when you're a patient, especially when you're there 1/4 of the year, but probably not the best way to exchange nosocomial organisms.
--Poor 8 year old girl who presented with a history of 3 days of fever including a fever of 105.7! I can't even imagine how miserable she must have felt. Blood culture grew Streptococcus. Thanks to the miracles of medicine, her stuffed Tigger and she were discharged today.
That's it for now. I'm post-call and it's time for bed.
July 1, 2009
Post Call Delirium.
Had my first night on call last night. Lot of fun!
Time really flew by, even though of the 31 hours in the hospital, I was working for 29 of them.
3 admits. Asthma exacerbation, viral tracheolaryngitis (croup), and cellulitis.
1 PICU tranfer. DKA.
0 emergencies.
2 Starbucks venti coffees.
1 presentation of childhood nephrotic syndrome prepared.
2 H&Ps completed.
2 bloodshot eyes.
1 pair of dirty scrubs.
We're on holiday this Friday so I'll try to update with some thoughts of my first week in The Big Time aka the wards at that time.
Time really flew by, even though of the 31 hours in the hospital, I was working for 29 of them.
3 admits. Asthma exacerbation, viral tracheolaryngitis (croup), and cellulitis.
1 PICU tranfer. DKA.
0 emergencies.
2 Starbucks venti coffees.
1 presentation of childhood nephrotic syndrome prepared.
2 H&Ps completed.
2 bloodshot eyes.
1 pair of dirty scrubs.
We're on holiday this Friday so I'll try to update with some thoughts of my first week in The Big Time aka the wards at that time.
June 25, 2009
So, Third Year.
So tomorrow marks the end of our "Transition to Clerkship" week, which means at this point I'm supposed to be pretty much transitioned to whatever this "clerkship" thing is supposed to be.
In the past I had (arguably) witty food analogies for the first two years of medical school. First year is like a hot dog eating contest. Second year is like trying to polish off that 72oz steak at Billy Joe's Steak Emporium. If I had to come up with an analogy for what transitioning to MS3 would be like... it'd probably be analogous to that NBA commercial involving Yao Ming (still one of my faves):
Yes, third year is like trying to eat a live crustacean. It's new, it's exciting, it's exotic, and you have no idea what the f*ck you're supposed to be doing. You can google how to eat a live crustacean, people can tell you how to eat a live crustacean, but until you've actually gotten out there and done it, you really have no sense of what its like. And when you try for the first time, its awkward, you fumble around, and you generally look like an idiot.
Our week started off with a morning full of "talks" from the big wigs in the School of Medicine who never appear unless something "important" is going on, which basically consisted of them reminiscing to us about their own days at the beginning of their clinical days. Luckily things picked up at that, and the rest of the week has been very fun. Finally had my first quasi-patient which I had to do a full H&P on and present the next morning. The rest of our time has been filled with workshops filled with how to scrub for the OR, knot tying and suturing, intubation, accessing/reading/interpreting path reports, how to place an IV, managing acute patients, etc, etc. The material has varied from interesting to repetitive, but the best thing is that is have all been HANDS ON. It's all been simulated, but actually getting your hands dirty and having things be interactive beats the hell out of sitting in lecture all morning and then hurrying up to sit in front of your syllabus the rest of the day.
Start peds on Monday. 2 weeks on the general wards then 3 weeks in the PICU. Hoorah.
In the past I had (arguably) witty food analogies for the first two years of medical school. First year is like a hot dog eating contest. Second year is like trying to polish off that 72oz steak at Billy Joe's Steak Emporium. If I had to come up with an analogy for what transitioning to MS3 would be like... it'd probably be analogous to that NBA commercial involving Yao Ming (still one of my faves):
Yes, third year is like trying to eat a live crustacean. It's new, it's exciting, it's exotic, and you have no idea what the f*ck you're supposed to be doing. You can google how to eat a live crustacean, people can tell you how to eat a live crustacean, but until you've actually gotten out there and done it, you really have no sense of what its like. And when you try for the first time, its awkward, you fumble around, and you generally look like an idiot.
Our week started off with a morning full of "talks" from the big wigs in the School of Medicine who never appear unless something "important" is going on, which basically consisted of them reminiscing to us about their own days at the beginning of their clinical days. Luckily things picked up at that, and the rest of the week has been very fun. Finally had my first quasi-patient which I had to do a full H&P on and present the next morning. The rest of our time has been filled with workshops filled with how to scrub for the OR, knot tying and suturing, intubation, accessing/reading/interpreting path reports, how to place an IV, managing acute patients, etc, etc. The material has varied from interesting to repetitive, but the best thing is that is have all been HANDS ON. It's all been simulated, but actually getting your hands dirty and having things be interactive beats the hell out of sitting in lecture all morning and then hurrying up to sit in front of your syllabus the rest of the day.
Start peds on Monday. 2 weeks on the general wards then 3 weeks in the PICU. Hoorah.
June 16, 2009
The Aftermath
I survived Step 1.
It still seems surreal to say it. That the seemingly insurmountable task that has been hovering over my head for such a long time is now over and done. In the past.
All that remains is the aftermath. My First Aid binder with pages ripped through their 3 hole punches, hanging out like a dog's tongue after chasing one too many frisbees. Dead highlighters on my desk. Sheets full of self-made diagrams and flowcharts. Sentences underlined in red with "QUESTION!" written next to them. My Goljan book, with its binding cracked down the middle and the second half of the "Hepatobiliary and Pancreatic Disorders" chapter hastily scotch taped back in. 3,400 QBank questions tucked somewhere in my cranium. 2,400 notecards sitting no longer of use on my laptop.
I'll post more about my experiences with my progress doing questions, taking NBMEs, and the like when I get my actual score back and know how accurately it actually projected how I'd do. But I thought I'd talk a bit about the experience of the test. My actual test day went pretty well. My immune system made one last rally and with my prophylactic DayQuil in hand I kept the congestion and runny nose at bay throughout the day. I arrived for the test a half hour early, and found myself starting the exam early at 7:40am. All those hours doing questions paid off and I found my stamina was good enough that I could bang out two hours of question blocks at a time between breaks. Time goes VERY quickly while you're taking the test. You find yourself so focused on each question that blocks can seem to fly by, and hours of the day silently tick away. Before I knew it, block 7 rolled around and I clicked that final "End Block" button and half-assed my way through the survey at the end.
What does it feel like when you step out of the testing center? It's a strange combination of exhaustion, exhilaration, and denial. It didn't sink in for almost two days that I was done. That there was no more studying to do. The day itself almost felt like just a long day of doing USMLEWorld, as the interface, pacing, and question prompts were all so similar.
But it does finally sink in. And its a great feeling when its over. The sheer amount of concentrated will it takes to study endlessly, day after day without reprieve, was honestly something I wasn't sure I had in me. Its a time filled with highs and lows. Lots of lows. Frustrations, and sometimes despair. You realize you have gone days without talking to another human being, and find yourself unable to engage in normal conversation when you do. You become robotic in your routine. Wake up, study. Eat only because you have to. Study. Sleep. Repeat.
I think if I had to sum up the entire experience it would be: I would never want to repeat it. But I'm damn glad I went through it. And now its time to sleep.
It still seems surreal to say it. That the seemingly insurmountable task that has been hovering over my head for such a long time is now over and done. In the past.
All that remains is the aftermath. My First Aid binder with pages ripped through their 3 hole punches, hanging out like a dog's tongue after chasing one too many frisbees. Dead highlighters on my desk. Sheets full of self-made diagrams and flowcharts. Sentences underlined in red with "QUESTION!" written next to them. My Goljan book, with its binding cracked down the middle and the second half of the "Hepatobiliary and Pancreatic Disorders" chapter hastily scotch taped back in. 3,400 QBank questions tucked somewhere in my cranium. 2,400 notecards sitting no longer of use on my laptop.
I'll post more about my experiences with my progress doing questions, taking NBMEs, and the like when I get my actual score back and know how accurately it actually projected how I'd do. But I thought I'd talk a bit about the experience of the test. My actual test day went pretty well. My immune system made one last rally and with my prophylactic DayQuil in hand I kept the congestion and runny nose at bay throughout the day. I arrived for the test a half hour early, and found myself starting the exam early at 7:40am. All those hours doing questions paid off and I found my stamina was good enough that I could bang out two hours of question blocks at a time between breaks. Time goes VERY quickly while you're taking the test. You find yourself so focused on each question that blocks can seem to fly by, and hours of the day silently tick away. Before I knew it, block 7 rolled around and I clicked that final "End Block" button and half-assed my way through the survey at the end.
What does it feel like when you step out of the testing center? It's a strange combination of exhaustion, exhilaration, and denial. It didn't sink in for almost two days that I was done. That there was no more studying to do. The day itself almost felt like just a long day of doing USMLEWorld, as the interface, pacing, and question prompts were all so similar.
But it does finally sink in. And its a great feeling when its over. The sheer amount of concentrated will it takes to study endlessly, day after day without reprieve, was honestly something I wasn't sure I had in me. Its a time filled with highs and lows. Lots of lows. Frustrations, and sometimes despair. You realize you have gone days without talking to another human being, and find yourself unable to engage in normal conversation when you do. You become robotic in your routine. Wake up, study. Eat only because you have to. Study. Sleep. Repeat.
I think if I had to sum up the entire experience it would be: I would never want to repeat it. But I'm damn glad I went through it. And now its time to sleep.
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