Peds Externship: Week 7

Second to last week of the externship, wow!

Peds Externship: Week 7

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Monday

As usual, Monday is a clinic-heavy day. I think by this week I had the opportunity to work with each of the 5 attending physicians. I must say, each attending is quite unique in his/her own way.

Dr. N is the residency director. He has such a soothing voice and very calm facial expressions. He has some weird ability to put almost any kid at ease. And he's very patient. Dr. O is perhaps the eldest attending of the group, and I think she's the program director. She's very grandmotherly and I just love working with her. Dr. W is rather jovial, kind of like a geeky kid meets Santa. He loves research and thinking about the interesting stuff. (There are 2 Dr. V's, so one's Dr. Ve and the other's Dr. Vo.) Dr. Ve, his counterpart in many ways, is very direct and to-the-point. He walks through his logic quite efficiently. And lastly, Dr. Vo is perhaps the most amusing (and youngest) attending of the five. She's a fast-talker, full of energy, and gives off this ADHD feel about her. She loves to go off on tangents and laugh, and she cracks us up a lot.

Tuesday

We meet up early in the day to round on this one patient (Patient 1) that was admitted over the weekend under Dr. O's service. She thought the kid was going to die overnight - everything was going wrong and things were so so complicated. She was so fragile in the PICU. The fellow and Dr. Vo (the attending now on inpatient service) went up to another floor to see, what was supposed to be, a short stay patient (Patient 2). Instead, symptoms appeared with that kid and they were away on that floor for 2 hours while we sat twiddling our thumbs in the PICU waiting for them.

They finally returned and we rounded on this girl together with the ICU team. After that, it was close to lunch. After lunch, we met up on the floor where Patient 2 was staying. Then we get a call from the emergency department (ED) that one of the patients under rheum was there with a stroke. So several of us went down to see her. While the M4 and I waited to see her, one of the senior residents had already seen her and had written up the note. So we went back up to the floor without having actually seen or talked to her. Grrr.

The day ended with much frustration between the M4 and I, because we both felt out of the loop and out of the decision-making with these 3 patients. We saw none of them, we weren't clear on what was going on with them, and we couldn't remember them. So our day ended rather disgruntled.

Wednesday

It was another clinic day, and it was a good clinic day. Towards the end of the day, I saw this one patient, a little girl, with the M4 and then Dr. O. The mom had brought her 15-month-old brother with them to the appointment. He was so full of energy, just bouncing around the room and climbing on everything he could. So adorable!

After the M4 and I did the interview and physical exam, we went to get Dr. O. One of the tests Dr. O had the patient do was to jump on one foot. The brother saw this and attempted to imitate her. Now, developmentally, kids aren't supposed to be able to balance on one foot until they're about 4-years-old. So obviously he failed, lol. But it was so funny watching him try! He just sort of cocked one of his legs and shifted his weight to the other leg, but he couldn't actually jump so just stood like that. The puzzled look on his face was priceless.

Thursday

Like Tuesday, it felt like a long and somewhat frustrating day. But it wasn't too bad. After going over the weekly review of clinic patients, the residents, the M4, and I were dismissed. The attendings and the fellows, along with the nurses, had their business meeting. So those of us who were dismissed hung around in the residents' lounge for the next 2 hours or so. Bleh.

We get the page to round, so off we went to meet the fellow and Dr. Vo. So we round on the patients and discussed at length what they might have (or might not have) and what exactly was the best course of treatment for all of them. We then went down to radiology (it feels like we do that a lot) to have them point out to us what they think might be CNS vasculitis. This time we were smart, because we headed straight for interventional neuroradiology instead of "normal" radiology, lol. Of course, CNS vasculitis is one of the most difficult diagnoses to give because it's so difficult to prove that it exists unless it's really bad.

Friday

More rounding on the same 3 patients! Actually, Patient 3 (the one from the ED) was transferred to the adult rheumatologists at the hospital next door and was discharged yesterday. At noon, the M4 and I went to a neurology case conference on Patient 2. I must say, they hold their case conferences in a really nice room on the administrative floor. But it was so boring. I learned nothing new concerning this patient, everything they said had already been said. By them.

Anyway, after that, we had lunch and then rounded some more. Patient 1 was stable and actually starting to get better! Patient 2 was off to radiology for more imaging, and then went home. Patient 3 was already gone. It was actually a pretty good day of rounding, and it's always good to know that patients bounce back and start to do better.

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Labmate's Wedding

So a couple Fridays ago, I got the day off from my peds externship to attend Jim and Aimee's wedding. Jim was one of my anatomy labmates and it was really nice of him to invite us. The other people in my lab group - Ritu and Mallory (and their significant others) - decided to go together and I hitched a ride with all of them.

So after over 2 hours of driving with bouts of traffic, we made it to the wedding just in time. It was a very nice, simple, and to-the-point wedding that lasted probably no more than 30-40 minutes. The pastor was really amusing and that made things less . . . solemn. We sat towards the back since we were among the last to arrive, but even so we could see Jim's smile all the way at the front - the biggest smile I've ever seen on him.

Just married!

After the wedding ceremony, Jim and Aimee walked to the front and greeted people one by one, which we all thought was really great of them. Because we sat near the back, we were among the last to be greeted. We then made our way to Mallory's hotel room to lounge about for an hour or so before the reception.

Mallory's amazing hotel room.

The reception was quite nice. There was a slide-show playing of Jim and Aimee throughout the years. They had known each other since 4-years-old, and really, this was all almost like a fairytale or a movie story. Aimee's dad cried when he gave his little speech, and even Jim - who we noted for his calm and level nature - had a brief moment before he caught himself. It was very endearing.

First dance.

There was this little kid, probably no older than 2- or 3-years-old, who kept running around on the dance floor blissfully. I must say, this kid kind of made my night. When other people were dancing he would still just run about, weaving in and out around the adults. There was also a moment where the only people on the dance floor were kids, and the flower girl really loosened up then.

Little kid dancing next to the newlyweds.

Kids on the dance floor.

After a bit of dancing (reluctantly on my part) and some chatting with the newlyweds, Ritu, her boyfriend, and I left at around 11pm since we had a long drive back. Mallory stayed behind because she was staying at the hotel there over the weekend.

We were all so happy for Jim and Aimee, it seemed meant to be. :-)

Backlog: 07-16-10

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Peds Externship: Week 6

So I'm now done with 3/4 of the peds externship. Wow. How summer has flown so far!! Many of my previous posts have been quite lengthy because they all span a week's worth of stuff. This one probably won't be much different . . .

Peds Externship: Week 6

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Monday

Along with Wednesdays, Mondays are primarily clinic days. So most of the day was spent in clinic seeing patients. It seems that there are 2 age groups of patients in peds rheum: little kids (younger than 6 or so) and teens. At one point, I did a joint exam with one of the interns. There are a lot of joints to examine! And I forgot to look at a few until we were through with almost all the joints. On this one kid, I wasn't sure if his knee was swollen or if it's just chubby from fat padding around it.

After clinic was over, we went to check up on the KotW from last week. He looked almost 100% better! Practically all his neurological symptoms were gone. Since Dr. W was off service and Dr. O was now on service, we saw him and his parents with her (we being the whole rheum posse). Dr. O gave him the okay to go home, but he still had to come back once a month or so to get treatment for the next few months, to make sure his symptoms don't return.

I must say, it's really good to see a patient that looked like he was going downhill make more or less a full recovery. I didn't even know you could almost fully recover from mini-strokes! Maybe that's just part of being a kid, the whole "reserve capacity" thing.

Tuesday

The day began with weekly teaching. The senior fellow, Dr. S, gave the lecture on differentiating between the different types of arthritis that kids can get. It was a long talk. Interesting, useful, but long. The talk could've been easily (and conveniently) broken into two parts. Oh well.

Partway through the lecture, the first-year fellow (Dr. K) got a page. She then returned with a huge patient file. At the end of the talk, Dr. S looks through the patient's records and goes, "Holy shit! This is a very complicated case! Are they sure they want to consult us?" This kid had been in the hospital since April and has seen so many teams - cardiology, critical care, GI, ID, pulmonology, and now us (and perhaps a few others). The fellows really didn't want to take this case because it looked like there wasn't anything we could do to help. So they dismissed us for lunch while they talked to the attending about whether or not to proceed. Just as I left, I saw the kid's name on the chart. It was one of the kids I saw while on peds ID about a month back! Same kid that had the 3-4 infected lines placed in him. Honestly . . . I was surprised he was still alive.

So after a few hours, we get a page to meet the fellows outside the kid's room. Apparently we took the case. Soon the attending, Dr. V, joined us. Even though Dr. O was on service, Dr. V was the best person to call because he's apparently double-boarded in peds rheum and immunology. We look at the kid's EMR (electronic medical records) for a while, and he was on so many drugs! As we scrolled down his list of drugs, one of the interns remarked, "Good God, is this a VA patient I'm looking at?!" Apparently, the old veterans at the VA are on a lot of drugs, lol.

We finally examine the kid. His liver was so enlarged that it grew down to his pelvis. Dr. V exclaimed, "If you can't palpate this liver, then you shouldn't be in medicine." He's right though, that liver was very easy to palpate. We then went back to a conference room to discuss his case. Dr. V kept asking all these immunology questions that I think none of us really knew the answers to, so we all kept quite while he talked. One thing I remember as we were walking to his lab to look at some flow cytometry data, is Dr. V saying, "And in toxic shock syndrome, almost all your T cells are activated. You don't want 90%+ of your T cells activated because then you die."

In the end, we were never able to come up with anything to help the kid (we were called because he had persistent fevers for over a week now) so we removed ourselves from the case. I'm not sure how long they can keep this kid alive, as he's waiting for a double heart and lung transplant.

Wednesday

Another clinic day. Pretty laid back, saw more kids. There was this one kid I saw who had multiple joint injuries in the last. He was a big kid. A football player. One who wants to eventually play for UM-Ann Arbor. ^_^ He weighs about twice as much as I do (if not more) and though he's about a decade younger than me, he's projected to grow taller than me by about a foot. o_O At any rate, he had no rheumatological problems.

There were a few rather shy/nervous little kids. Dr. N, who also happens to be the peds residency director, came in to take charge. I don't know what it is about him, but I swear he hypnotizes kids with his voice and calm facial expressions. They'll let him examine them when no one else was allowed to. Also, he has this nifty trick where he can guess what the kid had for breakfast when he examines their bellies. I must learn this trick, lol.

I thought that Wednesday might end early. Sadly, I jinxed myself. Just as I thought the afternoon patients were about done, 2 new patients showed up. Dr. N went to go see them and asked if I wanted to tag along. Of course I couldn't say no. He spent a long time with both patients. One of them didn't have anything rheumatological, the other had Raynaud's syndrome that I could've diagnosed from her chart. But Dr. N had such a fun time talking to her and her mom. Ah well.

Thursday

Similar to last Thursday. Just went through clinic patients for the following week. But instead of having a journal club, we had a demonstration instead. Dr. V knew an adult rheumatologist in another city who specializes in using ultrasound to do joint injections. So the rheumatologist came and gave us a demonstration using the ultrasound.

It was pretty cool, though I couldn't figure out what I was seeing on ultrasound most of the time. It does make sense to use ultrasound to guide needles into small joints, because they're hard to get to without doing at least some "collateral damage" along the way.

In the early afternoon, all the externs went to tour an inner city, grass-roots, non-profit organization. It was pretty amazing to see all the things going on there! As part of APAMSA (Asian Pacific American Med Student Association), we hosted a health fair there with other student groups several months ago. But even then I hadn't seen most of the place. Afterwards I got to talk to the person who gave us the tour about the possibility of continuing the health fair for this coming academic year. ::Crosses fingers::

Since there were no consults, I was given the okay to just go home.

Friday

I requested this Friday to be off, since it was Jim's (one of my labmates) wedding. I couldn't miss that! More on that in another post. :-P

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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.

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Peds Externship: Week 4

Week 4 was my last week in primary care pediatrics in the inner city. Truthfully, it wasn't much different than Week 3. But here it is:

Peds Externship: Week 4

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Insurance issues surfaced with a few patients this week. It's so frustrating. This one kid needed to see a dentist, bad; but it seems that no dentist in the entire city was taking their insurance. Every place on the Medicare/Medicaid list wasn't taking new patients. And the dental clinics that might've had long wait-lists. It's quite simply ridiculous that this is even an issue at all here in the US. Such is the reality. The pediatrician called in the social worker to deal with the insurance issues. When the social worker reported back to the pediatrician, he was just like, "No disrespect - I see you talking, but all I hear is blah blah blah because I don't understand anything about insurance." Also, some insurance companies change their formularies (which drugs they cover) every few months - and it's quite difficult to keep up.

Patient punctuality has been an issue this week. Every evening, the pediatrician's schedule was completely booked with patients. But one day, there was a 2-3 hour block where no patients showed up. o_O It wasn't even that they were late, they just didn't show up and didn't call to cancel. That was really frustrating, as I was bored out of my mind enough to take a nap. Next to the pediatrician. Oops.

At least I saw lots of cute kids during Week 4. There was a family of 3 that came in, and each kid kept giving me a book to read to them and such. It was quite adorable - though we were in the middle of a clinic visit, so my attention was divided. And the babies cooperated with me pretty well. I'm glad to have left the clinic with my track record intact of having made no babies cry. :-P

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