Monday, July 31, 2006
Is this my life? Where?
My schedule this month is ridiculous. On call nights I am up most if not all of the night, so that's 30 plus hours without sleep. This last call I got the 2 am admission and could barely remember what questions to ask. Fortunately she was stable and we could sort her out in the morning (a little more anyway, she's actually really complicated and interesting: 14 year old girl with acute onset vertigo and hearing loss after a whistle was blown right next to her ear while playing soccer).
What really slowed me down this last call was having three med students working on most of my patients. It's nice when you have med students to write progress notes and it's actually great to be able to teach them a lot, but they are not as fast as I would be by myself (understandably) so it takes longer to get everything done. Which is okay.
Got to do the lumbar puncture this call again, too. Went much better than last time. We got in with only two tries. That little baby is interesting, too. She's only 15 days old and has this huge hard lump behind her right jaw. She has persist ant fevers and on CT the following day it looked like an abscess, so we're pretty sure that's what it is. But the real questions is why does this 15 day old have an abscess there at all? ENT was going to see if they could drain it either today or yesterday. The mom lives way far away and has no money or phone. The last time she called in she was at the bus station about three hours away, hopefully she'll be there when I get in this morning.
That's the other thing that cuts into my lifetime: on non-call days, we have to go in at 6 am and stay until 6 pm...everyday! In medical school once we were done with our patients for the day, we checked on to the on-call team and left, but not here. That is really a hard part. I really am the the hospital all the time. And up for admissions all the time. If I were in charge of the world, I'd change things around at the hospital schedule and systems level.
One of my other parents would agree with me, she's frustrated because her son can't get anything down on Sunday and she isn't included in rounds. I know that is hard. Plus he's pretty sick with HUS and just past the peak of his acute renal failure. He's miserable and, as a parent, she hates it and feels powerless. And, frankly, the way the system is at the hospital, we don't do much to help. In Cincinnati, we did "family centered" rounding, with the attending and the whole team AND, imagine this, the family present, so everything could be discussed at once and there wasn't a bunch of running around and having to check with this person or that person. It was all right there. The families loved it.
I could go on, but guess what? I have to get to work. I'm rounding on twice as many patients this morning because the other intern on the team has a day off. That's sixteen patients to see (when I don't know half of them very well) in one hour and fifteen minutes. It's impossible; I've already accepted that. I'll just do my best.
Friday, July 28, 2006
Lesson of his Heart
"We never should have sent him over there." The attending said with tears welling up in her eyes, "At least he would have had a few more days at home with his family and would not have had all of that stuff done to him and die in the hostpital on a ventilator and after repeated pain and fear. He should have died at home.
I don't know what happened. People have different ideas about how to treat patients. And seemingly different ideas about what is important to the patients. It is tough to walk between them as the lowest doctor on the totem pole and try to even know and then fight for what you believe is right for your patient. All the while fearing that you may, after all, be wrong to begin with. And what you may have fought for all along was nothing at all. And mattered to no one.
It breaks my heart to think of him. The last time I talked to him, I struggled through my Spanish to explain to him that they were going to "toque some agua" from his belly. "Como?" "How?" was his only response. I didn't know the word for needle so I tried to act it out...failing miserably I think. Just as his heart was doing as we spoke.
When the fluid came off of his belly, more just poured in from his blood vessels and his heart stopped being able to pump correctly, so it just stopped. It just stopped.
I want to remind myself that stopping is not quiting...or failing...that death is the natural end to life. That it is not the enemy, but part of the continuum. I want to remind myself of that, but it's hard to think of that when I think of him that last time I saw him. He was lying completey naked on his bed, flat, with the door open, his belly even more swollen, intubated, his hernia makind his right testicle swollen to the size of a grapefruit, he was surrounded by people doing something to him. Maybe we all need to take a lesson from his heart and learn when it is time to stop. Try your best to keep going, then grieve when the going is no longer leading anywhere, and then, when it is time, stop.
Drownings are more frequent in the states that are on the ocean, and Minnisota, which has so many lakes. That means here. That also means where I grew up. It also means Arizona. Drowning kills more children in the under five age range than moter vehicle collisions.
When I was younger we had very good friends who managed a large ranch just up the creek from us. Their yard was beautiful. And one of the irrigation ditches ran right behind the lovinly tended garden. I knew the two younger siblings, both of whom were older than me by at least a few years. I used to ride with M., the oldest all the time. I remember my mom telling me, though that she wasn't really the oldest, that she'd had an older brother who had drowned in the ditch behind their house when he was about three years old. I never knew him, niether did his unborn brother and sister.
The lecturer talked about what happens as someone drowns. First you try to hold your breath and you make it for about 90 seconds until your carbon dioxide gets so high that it forces your brain to try to breath...and you try, but you can't. You don't inhale water, though, because your vocal cords spasm when it hits. Only about 5 ml/kg make it in. It's not the water per se that ends up killing you. It the lack of oxygen and the subsequent stopping of your heart.
My brother's girlfriend had an other brother that she never knew either. They used to live out on a big ranch in the foothills. Very far away from everything, including medical care. There was a big reservoir out there. And the oldest son didn't know how to swim well enough. And they couldn't make it into town fast enough to get him help. He died as they were trying.
The mom has never been the same since. I think she still grieves his loss. And still fears the loss of her other children, despite the fact that they are all grown.
CPR can be life saving in a near drowning. I don't know if they knew how to do it, but even mimicking what you see on TV is better than nothing. In kids it is five compressions, two breaths, repeat. And do it right away, don't leave them to get help, start now. Even if they throw up and it seems disgusting, five compressions, two breaths, repeat over and over.
This past December, my roommates nephew drowned in their pool in Arizona. He was a cute little guys. And she was very attached to him. She is still in mourning from his loss. She has pictures of him up all over the house. And she keeps some of his ashes in a locket in her room. The loss of a young healthy child is heartbreaking. Her father lost his mind over it. Her sister, the mother, still seems grief stricken. Many marriages cannot survive the death of a child. Perhaps families sometimes cannot either.
Cover your pools, watch your kids around water every second, swim only where there are life guards. It never hurts to have an extra guard for your life...of the life of one who you love.
Thursday, July 27, 2006
Tuesday, July 25, 2006
"Ah, there's the rub"
My team had one of the most pathologically interesting call nights my senior had ever had. Some of my patients included:
- 10 year old boy who had Hodgkin's Lymphoma at 3.5 and now has horrible restrictive heart disease and really bad ascites and can barely breath his lungs are so compressed by the fluid in his abdomen and his intestines are pushed down into his scrotum through his indirect inguinal hernia. He's really adorable, though. Speaks only Spanish. I let him listen to his own heart (which had murmurs and rubs and gallops and is basically working really hard to keep beating) and he said, "Gracias." We are trying to figure out exactally what he has. He might need a heart transplant. I thought right away that he needed the fluid taken out of his peritoneal cavity but apparently they don't do that in kids much and so no one felt comfortable supervising me (even though I've done it before).
- 10 month old boy with some unknown congenital abnormalitiy with all sorts of things wrong with him in for really bad reflux. He has never eaten by mouth in his life (has a tube that goes directly into his stomach) and his Nissen fundoplication slipped and needs repairing. He is a sqirmworm fussbudget and his parents are very attentive and concerned. Sad part is that thay also have a three year old daughter who they rarely see because they are always with this little guy.
- 10 month old with intractable epilepsy.
- 5 year old with bad bloody diarrhea which turned out to be both E. Coli (o157) and C. Diff. My senior paged me when she saw the results, "I hope you washed your hands after seeing him!" We put him in contact precautions immediately and started antibiotics.
- 3 day old girl with possible sepsis who was so dehydrated that none of us could get any spinal fluid to test for an infection there, despite trying a total of 6 times. Poor baby.
- Patient who I had there for a while who went home today who had both of her kidneys removed because they were polycystic and taking up her entire abdomen and then some. She developed a reactive knee inflammation.
- 14 month old with Down's Syndrome and short gut whose central line broke and started squirting blood. Thankfully they could repair it without any further damage.
And then the rest of my team got some interseting patients, too.
- Pyloric stenosis
- Gluteal abcess v. cellulitis
I have a lot of decompressing to do about the night and would like to write more, but have to present a paper tomorrow which I have just printed and not yet read. Oh, to sleep, "to sleep perchance to dream"? I'll take the rub at this point!
Sunday, July 23, 2006
I consider myself very lucky to have grown up surrounded by peach orchards where, each summer, we would buy flats and flats of peaches which would tantilize us with their sent as we drove the 3.4 miles home. Upon entering the house with our golden goodness, the scent drew the crowds. My brothers' friends (always up for any food) flocked. My dad grabbed one and ate it without even washing it first. My grandpa likes his cut in half and eaten over a bowl. Mom prefers them cut up in her cereal. I like them anyway. Each summer, while they were in season, I practically lived off of the fuzzy fruit heaven of peaches.
When I moved to Washington, then Santa Cruz, then Davis, then Cincinnti, I could never find peaches like those I had at home. I would wait patiently all year. I could understand that those inferior middle of winter peaches couldn't compete, but surely by the time summer rolled around and I knew the trees at home were ladden with sweet soft peaches they could get them to my part of the world, wherever that happened to be that year.
I ultimately ended up blaming in on Ohio. Even in the best grocery stores priding themselves on their superior produce, their peaches could not compete with those I'd had as a kid. Now you may think that this is an exageratted childhood recolection, like memories of how much fun Chuck-E-Cheese is until you visit it again as an adult, but I assure you it is not. For I have been back to the homeland as an adult and the peaches are as good, or better, than ever.
This lack of good peaches anywhere else does explain a few things I wondered about as a kid, however. For instance, when I was enjoying my peach with the juice dripping down my chin and the hose and creek nearby to wash off the sticky sweetness, I wondered, "How is it possible that everyone in the country, if not the world, buy up and eat all the peaches available to them the second they ripen?" Now I know. When the peaches in grocery stores are the consistancy of apples, they are not peaches the way they are meant to be. They are not peaches at their best. They are simply the subpar "shippable" or "marketable" type of fruit--the poor relation to the peaches I knew growing up.
The second conundrum regarding peaches involved an annual pilgrimage made by two of our very close family friends who lived about five hours away. Every year, they would come to visit and plan their trip around when the best peaches were ripe. For me, living in my own Garden of Eden, it seemed like a lot of trouble to go to just for a few peaches that I (erronously) thought could be obtained at any decent grocery store. My years and my travels have indeed shown me the error of my ways. Peaches like those I had as a child are precious; they are worth the trek; in fact, they are worth more than that.
As of this instant, I have a flat of peaches sitting in my refridgerator. They looked fine; they are...fine. They are the the golden red that peaches should be, but even from looking at them you can start to guess that they will not be the same. They are simply too round and firm looking. The peaches I want are slighly dimpled where they have been tenderly touched by the picker and the boxer. They are soft to the touch, and not just because of the short fuzz, but also because of the tender give of the flesh under the thin skin.
The peaches I have in my refridgerator are not like this. They have a greenish tinge when I turn them over and they are as hard as apples, or baseballs. I ate one anyway, hoping the poor cousin would at least bring back the memory of my childhood peach princes. If I cut them into thin enough slices (that is the other thing...real peaches should barely be able to be cut in half, and slicing them just makes a juicy mess)--if I cut these into thin enough slices, though, they are soft enough and recall a sweeter past. I have set one out on the window sill in the hopes that it will somehow mature into it's best self.
It is not the peaches' fault after all. They have been torn from their orchard homes much too early. Long before they could coax the sweetness out of the ground and into their flesh. Long before they became too tempting for the birds and insects. And long before they have reached their full potential.
"Let them ripen!" I say. All the time knowing that if they were really allowed to ripen, they would never reach me at all. They would be soft soggy, perhaps even moldy, messes by the time they were thousands of miles away from their home tree. Some things must just be enjoyed where they belong. You can take the peach out of the orchard, but it looses something in the transition.
Thursday, July 20, 2006
Two Week Roll of Toilet Paper
And I'm not talking about being conservative with it. And it's not one of those giant rolls that have the cartoon bears doing their business in the forest. It is a normal old roll of toilet paper. It is just attached to an abnormal life.
I'm never home. When I am here, I just fall asleep. Sometimes on top of the covers. Sometimes under the sheets. Sometimes on the couch. Occasionally I wake up and rummage through my rapidly becoming barer cupboards for something fast to eat before I fall back asleep.
I got home from work today at 9 am, after being there since 6 am the previous day. This was actually a treat since I got out three hours earlier than expected. I came home and slept. I'd been up most of the night finishing my off service notes. I woke up at 3 pm and ate a bowl of cereal. I'd had nothing to eat since the ice cream sandwich around midnight the night before.
See what I mean about an abnormal life. Who lives this way? I mean really.
I just heard from another friend of mine from med school who is now a surgery intern in Oregon. He just eats and sleeps and works, too. And better yet, his time at work is spent lancing perianal abscesses (butt puss bags). I've done a few of those...they aren't fun...especially for the patient. Even the toughest guys writhe in pain when you're getting all the puss out.
The worst my patients have on their tooshies is a diaper rash (cholestyramine in aquaphor, no scalpel required).
This last call day was my last in the NICU until my third year. I was actually a little sad to leave. It is a funny little world but when you spend enough time there it becomes your own funny little world in part.
Several of the parents of my patients were in last night and I spent hours talking to them (part of the reason I was up until 4 am finishing the rest of my work). One mother in particular who I talked to for a good hour and a half. She had many questions about her twin premie babies.
Someone has told her when they were born that she shouldn't buy them anything or get too attached because they might not make it. True, they are sick and tiny, especially the little girl who was my patient, but in my opinion that is no reason to not love them. I talked with her about it a lot and told her that if anything, loving them helped them heal. If she lost them, it could be hard for her, that is true, but if that is a risk she can accept, then love them. Love them all you want and more. I don't think love is ever wasted if it is whole and true. She kissed the isolete and mumbled to her daughter in Spanish as she was saying goodnight to her. "Te quiero," I overheard. "I love you."
There was another little girl born last night--a term vaginal delivery. We usually aren't called to these unless the OB residents already know there is something wrong, so when the intercom squacked, "Peds to LDR 1," we figured something was funny. We go there and the baby was already out. We bulb suctioned and dried her. She was sort of blue and quiet so I rubbed her feet to irritate her enough to cry and breath. She did and ended up breathing fine.
But she looked different. She looked like she had Down's Syndrome. Often this is something that parents will know before the delivery. But for these parents (mother was age 40 which increases the risk dramatically) it was a complete surprise. The dad looked older too, but you could tell right away that he loved his daughter, "Que linda," he said as he kissed her repeatedly and gently on her little forhead. "How beautiful."
Later when we had the baby in the nursery, the aunt and friend were holding her. The aunt had to leave because she was crying. This baby would change their life in ways they had not imagined. She would not be the "normal" little girl they'd expected. Now they didn't know what exactally to expect. All they seemed to know is that they loved her anyway.
A few days previous to her birth, we'd had a little boy come in with Treacher-Collin's Syndrome. He would have a 95% chance of developing normal mental functioning, but he also had several facial and auditory features common to the syndrome that could compromise his airway, hearing, and his future social interactions. He was the first born of the couple. The father never left his side through all of our rounding and consults and discussions. He just stood there watching his son and staring at him. He didn't know what to think. He was stunned. It was like he was deciding how to be with this little person who, again, was not what he and his wife had expected. Even knowing what could happen, you never expect it...and even if you do, there is no way to prepare.
This afternoon when I woke up I cleaned up my room which had become nothing more than piles of stuff with a path from the door to the bed. I hung up some pictures. I vaccumed. I took a shower. I went to meet some of the other interns at a bar in the neighborhood, but they weren't there very long and I was on the phone getting half of my check out for tomorrow. I am taking over for two interns, which means I'll probably have a good 14 patients and have to be admitting more on top of that.
So I ended up just getting food and coming back home. I didn't feel like having cat tail in my face as I ate today so I closed Charlie in P's room. He has been meowing his head off ever since and when I checked on him I saw that he'd already pooped three inches in front of the litter box. He's staying in there tonight. And I'm wearing ear plugs.
Overall, it's worth it to have the toilet paper roll last two weeks. I'm exhausted and I'm frusterated and I'm lonely, but I'm learning about healing and love. It was my choice and I entered it knowing the sacrifices I would have to make.
Plus I haven't had time to go to the store to buy more toilet paper.
Facts Learned in the NICU
- Caffeine past adjusted age of 32 weeks is not helpful (to restart)
- Decrease the lipids by half when you have reached 50% of oral feeds; stop them all together when you reach 75%
- Enfameal AR is thicker but it is not compatible with PPI
- PE has more vitamins for little ones
- ROP = retinopathy of prematurity = the blood vessels at the back of the retina don’t grow out to the edge of the eye until 40 weeks gestational age or after, when you have a premie they are not anywhere near where they need to be. Oxygen is toxic to these vessels. The need frequent eye appointments to look at the vessels and grade where they are: “Immature zone II.” If the vessels begin to get disorganized, they will have to be treated with laser surgery and hopefully will regrow in the right direction. This does create small blind spots in the peripheral vision.
- CLD = chronic lung disease = defined as requiring oxygen past 32 weeks gestational age
- RDS = respiratory distress syndrome = treat with surfactant
- AOP = apnea of prematurity = breathing centers are not developed in even the term newborn; these are very undeveloped in the premie. When they get hypoxic, the centers become even less sensitive to CO2—a bad downward spiral
- PPHN = peripheral pulmonary hypertension of the newborn; newborn circulation in a term baby; lungs capillaries don’t relax
- SIMV = give PEEP/PIP; time to take off when 18/5
- NCPAP = give PEEP, usu lowest is 5
- HiFi = crazy vibrating thing that provides constant opening of the airways; supposed to be more gentle to premie lungs
- INO = inhaled nitrous oxide; to dilate vessels in the lung in PPHN
- Babies need a carseat test before they go home
- Reflux precautions at 45 degree angle
- Careful of NEC and feeding advancement
- Glycerin 0.5 ml pr prn no stool in 24 hours
- Lansoprazole better in newborns than ranitidine?
- The first two days of life, give life in hours instead of days
- Dextrose infusion rate: (([dextrose] x rate)/weight)/6 want a glucose infusion rate in HAL of no more than 12-14 mg/kg/minute
- Don’t put more than 12.5% dextrose in PIV HAL, don’t put more calcium in PIV (infiltration)
- When HAL, check BMP, mg, phos, triglycerides to adjust
- Intubation medications: atropine, fentanyl, mev
- Diabetic Fetus: polycythemic, increased fibrinogen, delayed lung maturation, “soggy” lungs leading to “big baby RDS” leading to pulmonary hypertension and tricuspid midsystolic murmur
- 1/3 of the fetal lung fluid is cleared by the TSH surge in vaginal delivery
- Writing the delivery note “Peds call to the vaginal delivery secondary to… Infant handed to us floppy and blue. BBO2 used for 50 seconds. Routing NALS followed. Three vessel cord visualized. Baby brought to the ISCC.”
- Give gastroschesis babies lots of fluid! Cover the gut quickly. Stay sterile
- Ampicillin 100 mg/kg bid
- Gentamicin 4 mg/kg once a day
Saturday, July 15, 2006
What I Learned at the Beach
I learned that when a beer can is stabbed with a key it can spray a good 10 feet all over the back of my legs.
I learned what "shot-gunning a beer" is (see above).
I learned that evidence based medicine requires good literature searches (I was a dork and read a little bit).
I learned to remember my iPod.
I learned to be careful who I choose to camp next to. I think I would prefer cute playing children to drinking smoking 20 somethings talking about how breaking out of jail is a felony.
I learned that you can't have dogs on this beach (but people still do).
I learned that the sun through the pillars under the pier lights up the mussles so that they glisten.
I learned that people play with balls together to have fun (soccer, volleyball, baseball).
And big and little kids still like to play in the sand.
I learned that there is life outside of the hospital. And it is nice.
Charlie is Driving Me Crazy
It is not fun to come home to know that I have to clean up cat poop every day. Plus he is always anxious to have me pet him when I get home and meows and meows and follows me everywhere. He jumps on my bed when I take my keys to my room. He follows me into the bathroom. He runs around in front of my legs. Then when I do stop to pet him and give him some attention he is purring and appreciative for a minute before he decides it will be more fun to scratch and bite my hand.
The first few times he did this I just stopped petting him. Lately I have been pushing him away and reprimanding him. He hasn't done it as much since I started doing that. I don't know why he thinks it is okay.
In addition, there is cat hair everywhere. With the perianal cyst he was more stressed so I guess that may have made his hair fall out more. So it's everywhere.
And he likes to scratch on the carpet so it's torn up all over the place. They are going to have to replace the carpet here for sure. I just better not have to pay for it out of my deposit.
It's sort of nice to have another creature greet you when you get home. But it is also a bit of energy to care for him. And I just don't have any extra right now.
Tuesday, July 11, 2006
Which is what I should be doing instead of writing this. It has been a long day. I'm still in the NICU and I haven't caught up from last call night and I'm on call again tomorrow. Plus we have these evening learning lecture things that last until 8:30 two nights a week. I am at work from 5:30 am until 5:30 pm (at least) and then on call every fourth night (30 hours). It leads to exhaustion.
In addition, my roommate is gone so I'm cat-sitting and he is mad that I get home so late and always has a pile of poop waiting for me when I walk in the back door--sometimes two piles. What a way to make a statement.
In fact, that's what the babies do sometimes, too. Poop. But it's usually a good sign when they do.
The NICU is fine. Critical care, you know. Some of them are really sick. One very sick one came in today and the social worker had to call the priest to have it baptised quickly in case the likely outcome happened sooner rather than later.
Some of them are not so sick. We call them "feeders and growers." So the daily discussion goes something like this:
"Jones. Day of life 88. Adjusted age 36 and 1. Weight 2230. Up 30 grams since yesterday. FEN 145, 121, 3.1, smear. Eating MBM 20 with neosure. 34 q 3. Nippling 4/8." Then a crap load of additional vital signs and numbers that magically mean something. I've learned the new NICU language over the last few weeks. It's not so difficult; just a little dry.
Had my first day of clinic today, too. It is a combined med-peds clinic out in the boonies east of here. It was alright. I think everything looks not so great when I'm this incredibly tired. I'm just super irritable. I haven't had a day off in 10 days or something like that; then before that I worked 20 days straight. I'm tired.
Anyway, clinic was okay. I felt like a med student still. I don't even get to have my own panel of patients. And I was really looking forward to that. Good thing about that is that it's super flexible. Bad thing is that I don't get to have that experience. I might try it for this year and see if I can switch next year. We'll see. That would mean probably doing seperate medicine and pediatrics clinics on alternate weeks, which wouldn't be bad actually.
Plus I don't know what I'm doing with my life. Mike is right when he says that when you're tired is the worst time to think about it. Problem is, I don't know when I won't be tired.
Oh, and I have to take a four hour test tomorrow while I'm on call. Then was going to try to fly to San Jose for a wedding, but now the fellow wants me to be at work on Friday.
And all I want to do is sleep!
At least I snuck in a trip to the grocery store tonight. I got dark chocolate covered honey combs...among many other items. They are called Violet Crumbles in Australia. They're great. The store here sells them in the bulk bins. Yum.
Did I mention that I'm tired?
Oh, and I have no time to make or eat any real food, so I'm living off of Clif bars. They fit in my back pocket and I can eat them in under a minute. I just bought another 20 of them at the grocery store. Good thing they're still on sale. Eighty nine cents.
Keep in mind this is a tired rant. I'll feel better with some sleep...I hope.
Sunday, July 02, 2006
My cousin has decided than she is a lesbian. I don't really care what she chooses to do with her sexual preferences. I don't really think it will last, though (LUG=Lesbian Until Graduation). She likes to prove how open-minded and liberal she is and I think this might fit into that catergory. But my grandparents don't like it (which actually sort of surprises me) and won't let her girlfriend over to their place. So my cousin has not been out either.
Then there's the ongoing stuff (maybe resolving?) with my parents who are in Michigan together now.
And of course the tragedy with my aunt's brother being killed by his girlfriend.
Three days off!
Michael and I played at the beach and the park and ate out and had a great time. And every time we weren't doing something I tended to fall asleep. I think I am finally caught up on my sleep now. Maybe. I slept until 11:20 this morning after I got back from dropping him off at the airport at 6 am.
Tomorrow is back to work, though. And I'm on call on the holiday as well as all of next weekend. Monday's are tough, too because we have to get all sorts of extra labs and measurments and graph growth and stuff. It is going to be a long morning.
I am more in the groove of the NICU now. One of the other fellow interns has it about right when he says, "This is a strange, strange place." It is like it's own little world of little people.