Peds Externship: Week 5

I meant to write this a couple days ago, but I've just been so busy and things have been unusually hectic. Anyway, Week 5 marks my first of 4 weeks in pediatric rheumatology (henceforth to be called "peds rheum"). It's crazy to think that my peds externship is already half over!! Week 5 was a shorter week since we got Monday off for the 4th of July weekend. :-)

Peds Externship: Week 5

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Tuesday

First thing in the morning I meet up with Dr. N, the attending who's responsible for me. I also met the 1st-year peds rheum fellow (Dr. K) and the 2nd-year fellow (Dr. C). Peds rheum is a 3-year fellowship after the 3-year pediatrics residency.

Dr. C took me to see an inpatient kid while Dr. K waited to meet up with the rest of the peds rheum team. While reviewing the kid's chart outside his isolation room, Dr. C decides to pimp me on shingles. o_O I hadn't formally learned about shingles yet, but because I know a little bit about it, I was able to answer all of his questions but one. So what is "pimping?" Pimping is where a senior medical person asks a series of questions on medical facts to a younger medical person to test the limits of their knowledge. Earlier, Dr. N and Dr. C had discussed an article that came out called The Art of Pimping. And in that article is a section on defending against the pimp; I particularly like "The Muffin."

Anyway, we then met up with the rest of the team, which consisted of: myself, a M4 student, 2 interns (1st-year residents or PGY1), 1 second-year resident (PGY2), Dr. K, and Dr. C. An attending, Dr. W, would meet up with us later in the day. So the 7 of us walked over to a small conference room for "weekly teaching." Dr. C gave a lecture on lupus. I was particularly amused by the 2nd and 3rd slides, which was basically a picture of House saying "It's not lupus." Lupus is indeed an uncommon disease, and quite difficult to diagnose since there's no "typical" lupus patient.

After weekly teaching we got consulted to see a kid. So we trudge on over, the swarm of us, to see this kid with neurological symptoms. We referred to ourselves as the "rheum posse," lol. We didn't know what to do with him because it didn't at first glance appear rheumatological (as if I knew what that meant yet). We spend the rest of the afternoon, about 5 hours, working up this kid, interviewing him and his parents, and looking at what other consult teams (such as neurology, ophthalmology, etc) had written in his chart. After a few hours of discussion, the only diagnosis we could come up with was CNS vasculitis, which we weren't confident about. So we kind of took ourselves off the case, since it didn't really seem convincingly rheumatological.

Wednesday

So Mondays and Wednesdays are the 2 clinic-heavy days, where the majority of the time is spent in the peds rheum clinic in the hospital. The majority of my experience in peds rheum was to be spent in the clinic because there are so few kids on inpatient who require a consult from us. There were 3 attendings (Dr. N, Dr. W, and Dr. O) and 1 nurse-practitioner staffing the clinic this day, along with the 3 fellows (the 3rd-year fellow is Dr. S). Often between me, the M4, and the residents, several of us would enter a room to see a kid. Also, during the morning, a M3 student was in clinic with us as well. I'm sure most of the kids felt quite overwhelmed by the number of people entering their rooms.

Through the clinic, I see more of what peds rheum is all about. There were a lot of kids with various types of juvenile arthritis, such as: juvenile idiopathic arthritis (JIA), psoriatic arthritis, spondyloarthropathies, and Raynaud's phenomenon. I also saw some kids who had lupus that's currently being controlled with medicine and is in remission (kind of like cancer). Most of the kids looked more or less healthy with their arthritis under control, but the attendings tell me how bad a lot of them were when they first came in to the clinic.

At the end of the clinic day, we rounded on the inpatient kid again (who I'll refer to here as "Kid of the Week" or KotW). We had learned that earlier in the day he had some mini-strokes and was sent down to the PICU (pediatric ICU). So of course we had to go see him. When we get there, we encountered a very irritated critical care attending and his team. Shortly, the neuro consult arrived. The critical care and the neuro attendings then began arguing in the middle of hallway about the course of action for this kid. By this time, hematology/oncology had also arrived, but everyone was standing back out of the cross-fire.

After the critical care attending calmed down, we talked to the neuro team to see what they thought the kid had, since he had been in and out of radiology all day getting various imaging done. The neuro team then sends the kid over to get an angiography of the brain to build evidence that he indeed has CNS vasculitis. We wrote the note to start the kid on treatment for vasculitis, even though it hadn't been confirmed yet (and really, it couldn't be definitively confirmed because of how deep the problems were physically in his brain), just to hopefully prevent the kid from getting worse.

Thursday

The morning began with "staffing," where basically everyone in the clinic - including the nurses - get together and go through all the patients that everyone has in clinic, so everyone has some idea of what every patient has in case someone other than the primary care provider in that clinic has to see the kid. After that, we had a journal club meeting, where Dr. W gave this long PowerPoint presentation on a topic that was way above our heads. The residents, the M4, and I were all fighting to stay awake. And Dr. W called this "light and fun," lol. It most certainly was not - even though the paper was quite interesting.

Then we, the 8-person rheum posse, rounded on KotW again. He seemed to have improved a little (or at least, hadn't gotten any worse). We looked for the angiography report but couldn't interpret it, so we had to trek down to radiology to get a radiologist to interpret the films for us. I must say, I do not want to be a radiologist. The room they're all in is like a bat cave! It's pretty dim in there so they can see their computer screens more clearly. There were desk lamps at each station that gave an odd ambient effect. All the while, the radiologists kept talking into their microphones to dictate their findings; this gave the effect of a low constant drone or chant . . . it almost sounded like some kind of cult, lol.

Well anyway, it turns out that the radiologists couldn't help us, and so directed us to interventional radiological neurology (I didn't know one could even be that specialized). So we get down there and someone instantly explains the films to us. Clearly, it was also over our heads (even Dr. W, our attending), and so there was much nodding in false agreement.

We trek back in our little rheum posse to KotW's room to talk to him and his parents, who had been exceedingly worried (understandably). Our diagnosis seemed to be correct, so the day ended well.

Friday

Friday was just a brief day of clinic patients. With each passing day, I learn more and more about joint exams and how to do them, lol. Before I left, the M4 and I ran into Dr. C on our way out. He had rounded on KotW earlier, so we asked him how the kid was doing.

His neurological symptoms seemed to be improving which was reassuring. They wanted to keep him over the weekend to make sure he was alright until this week. Dr. C was only concerned about the dosing of aspirin that neuro put him on. As he pulled us aside, he pimped me on how aspirin works in the body. o_O I couldn't come up with an answer initially, so he kept pressing me for an answer. Eventually I remember the correct biochemical pathway (whew!).

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Throughout all this, peds rheum has been quite amusing, mostly because of the people. Also it was amusing since there were so many of us. Pretty much every level of medical education from M1 to attending-level was represented, and that's quite the achievement!

I spent a lot of time with the M4, and she really helped explain a lot of stuff to me. The interns and the residents were also all great to get along with. Even Dr. C, despite his pimping, was really nice. I'm convinced that pediatricians are the nicest pimpers, lol.

While I don't ever see myself going into peds rheum, I think this rotation will be quite enjoyable and certainly interesting.