Feb 10, 2010

Pediatrics Warrior, not Prisoner of War

I was dreading my pediatrics rotation. From what I could see, it involved barfy, sniffly, whiny, drippy, crying, germy children whose little ear canals are impossible to examine and whose heart and lung sounds are indistinguishable from their wailing. I figured that February 8-March 7, 2010 would be a black hole in my medical schooling; the doctor equivalent of torture training by the military for the possibility of being a POW. And that's what I would be: a POW in the pediatric community clinic.

What I learned today is that this is the picture of outpatient peds. Inpatient is different. And I LOVE it.

It was exciting. Pediatric consults in the ER, waiting for the product of a difficult delivery, kids in the NICU and pediatric ICU, one room with cribs stacked side by side filled with babies with respiratory syncytial virus, all waiting with no pretense for the care of a quick-minded physician. It was just my first day today, but I saw more of a gamut of problems than I had ever expected; things that I figured I would read about but never see.

There was one little guy in the ER with a history of imperforate anus and dependence on saline enemas. He was backed up to the small intestine, with his large intestine so distended that it was putting pressure on his lungs. Looking at the xray, I asked "Does he have Hirschsprung disease?" The attending looked at me and said "You know, I think you're actually right. I can't believe no one has diagnosed him with that." He saw a pediatric gastroenterologist that afternoon and is now being treated. I was pretty proud of that (and glad to make a decent impression on my first day).

There was another little baby with Down sydrome, sick with pneumonia. He was cute as a bug, with a mom who was only 15 but really trying to do the right thing. One kid we saw today was in the ER with pneumonia, but I thought that I heard a heart murmur along with the junk in his lungs. On the xray, the little guy's heart was dilated to the size of a grapefruit, with a nice patent ventricular septal defect. There were a set of twins born at 25 weeks, that the 14 year old mom had gotten pregnant with them when her first child (a preemie born at 30 weeks) was still in the NICU! There were a set of parents in the ER with a kid who didn't look too sick, but on further questioning revealed that they had a three year old that had died the year before after being sent home with a respiratory illness, so were understandably anxious. Besides that little guy, there were another two dozen with respiratory illnesses (RSV) sick enough to be hospitalized. The pediatric ward was full, so kids were spilling out into the postpartum ward, the L&D, and even adult med-surg. One scene reminded me of third-world medicine: because of a lack of beds, they had put makeshift cribs in one room and clustered several babies with RSV in there. We rounded on them one right after the other, talking with different families, in different languages, but about the common illness their kids shared.

One kid was a particularly interesting case. This kid was about two, and had been born with hydrocephalus. He was followed in the NICU, and then discharged. Since then, he's bounced from PA to physician at different clinics, and NO ONE has addressed (or even mentioned) the fact that this kid's head can't fit through his shirt. He's now got a sodium level of 120, probably from a mass effect on the hypothalamus causing a SIADH syndrome. And yet, when we looked at the CT read in November, the radiologist said that is was unremarkable. Um, hello? This kid looks like he was fathered by the Elephant Man. His ventricles stretch almost the longitude of his midbrain and the hemispheres are asymmetrical. I'm a student, not a radiologist, and I could see that. The pediatrician called up a buddy he had in San Diego that was a neurosurgeon, and asked him to reread the CT as a professional favor. He needs a shunt, so he'll get connected probably with Stanford Children's Hospital now. I hope he gets taken care of.

Another interesting kid was one that both she and her mother had coded (died) during delivery. Both were resuscitated. Mom was okay, but this kid is completely vegetative. She's graduated hospice twice now (does that get a cap and gown?), and her life consists of just hanging on between infections. However, her parents are fighting about the DNR order, so right now she's a full code. Dad says it is against his religious beliefs to let her die; mom thinks it is kinder to her daughter to let her escape this medically sustained life. Interesting, the ethical dilemmas that come up in medicine.

I think this is a very different picture than I might get in another hospital. Sometimes the negligence of care is shocking. Other times, the care is good but the facilities are lacking. In any case, this is an area of great need. The doctor I'm with says that he sees things here that statistically he should only see once or twice in a career, and yet he has had several cases in the last few years. Kids with Edward syndrome (trisomy 18), DiGeorge syndrome, one rare metabolic syndrome (there are only 5 documented in the world), high rates of acute leukemia, and others that are considered medical "zebras" but somehow become "horses" in this community. He thinks its because of the generations of farming pollutants. Sounds reasonable. I don't know. Either way, I'm grateful for the experience here. And I'm very grateful to have discovered a love for sick children that I didn't know I had.

1 comment:

  1. Another great blog from a great little doc.