Tuesday, February 20, 2007

Pediatric Patients

The other day I had an eight year old female patient with a chief complaint of vomitting, but a year long history of fainting ("syncope") approximately 20 times. It was strange. We asked all sorts of questions, but as it turns out not enough. She was usually standing up. Her mom had witnessed them and said she would start rocking before she collapsed. She was out for anywhere from 5-20 minutes, depending on who you talked to. Her mom woke her up by splashing water on her face. Her exam was normal. Her ECG was normal. She did not feel palptations. She did get head aches sometimes. She felt nervous sometimes. She had strange stomach aches at times. I thought it might be anxiety or vasovagal related, but it was a wierd history.

Still, the most common serious cause of syncope (in adults at least) is cardiac arrythmias. After having the medical student present the patient to the attendings, they were just as baffled as we were. So we got a cardiology consult. And he asked the right questions.

Turns out she drinks only soda; no water. And that everytime the syncope happens, she gets sweaty and nausous before she passes out. AND that it usually happens when her mom is brushing her hair.

She has "hair grooming" syncope.

I'd never heard of it either. But you can bed I won't forget it now.

Here's a 1988 article abstract:

"Department of Neurology, University of Tennessee College of Medicine, Memphis.

"We report 20 girls who experienced episodes of unconsciousness while standing for hair grooming. The episodes were syncopal in character, electroencephalograms were normal in most cases, and at least 11 of the 20 had definite episodes of syncope in other circumstances. A number of these girls underwent extensive diagnostic testing. We consider this a form of situational or reflex syncope, perhaps related to orthostatic hypotension, the recognition of which may spare unnecessary diagnostic and therapeutic interventions."

So we discharged her. Wierd.

The body does some very odd things sometimes.

Another of my patients, a 16 year old smoking, shrooming, toking, new onset type one diabetic, has this strange disconnect between his peripheral vessels mechanisms to do temperature control and deliver nutrients. Erythromelalgia. He presented with 10/10 pain in both his hands and feet. They were swollen and helped a little by ice packs. Treated with a high blood pressure medicine. He is going home, too.

A couple weeks ago I had an adorable little 4 year old girl with pneumonia, EF. She was in a room with another of my patients, MT, also with pneumonia. M., an 11 year old girl, was on 5 liters of oxygen and still breathing 60 times per minute at times (that's bad). E. was just hanging on to her last half liter of oxygen until, after a couple days, she finally had that weaned off, also. But as it turned out, she was the sicker one in the end.

Her mom was always at her bedside. Her dad and little brother had been in some, also. They were a wonderful family. As I visited them every morning and throughout their days there, we got to know each other better and I liked them more and more. E, would giggle at anything. I started looking up a few jokes for her. When we rounded with the team senior, she was usually eating her breakfast and my senior would tease her about sharing and she never would, as she sopped up some more syrup with the pancakes and shoved it into her mouth with a cute mischevious grin. Her mother smiled adoringly at her side.

to be continued...

Thursday, February 15, 2007


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I usually wake up with a song or a phrase in my head. Lately it's been "the wonder that's keeping the stars apart." I couldn't place it but it kept rattling around in my head. Bumping into thoughts about my new onset seizure patient who failed his driver's test yesterday. "the wonder that's keeping the stars apart" Running into my thoughts of my parents divorce. Colliding with my new/old relationships. "the wonder that's keeping the stars apart" Wrapping itself around the yarn I've been distractedly crocheting into teenie weenie beenies for my patients. "the wonder that's keeping the stars apart"

I googled it tonight; it's part of ee cumming's "i carry your heart" poem.

I can't google why it's been in my head, though. I wish I could.

I've been anxiously sharply distracted lately. Multitasking to keep my mind busy. Leaping ahead of myself. On the next thought before I'd finished the first one. And then crashing into all of them at once and landing on my ass.

I don't know what it is. Friends says it's because I'm stressed. I don't feel particularly stressed, not more than usual, anyway. Maybe that's the problem. I've learned to live with it to the point that I don't even recognize it anymore.

My job is a constant source of struggle, good struggle mostly, but still. And sometimes frustration. Especially in the winter at a children's hospital; patients are waiting in the ER for 12 hours regularly. I see them lined up outside even at 6 am when I drive up to work. It's not the patients, only, however, it's the system sometimes. The fact that I have to write re-admit orders for a patient who just went to the OR for PICC line placement under anesthesia. The fact that I can't even start a hypertensive med without running it by one of the attendings. There are attendings who will give me more input and let me make suggestions, but not all.

Then there's the divorce. It's so dumb. Both my parents are intermittently a wreck.

I'm sleep deprived.

I was trying to go off my lexapro. (bad timing--what was I thinking?)

I'm having a string of feeling fat days.

There's the whole relationship change issues.

But why "the wonder that's keeping the stars apart"?

Because there is still wonder.

I had clinic yesterday and one of my four year old well child checks was a cute little girl all dressed up in a tiny red blazer for Valentine's Day. She was there with her mom and older sister. She spoke only Spanish, so I did my best. She kept giving me Hershey's kisses and even a hug. I like being able to make her happy. I like being in the position to help figure out why she's having vague abdominal pain and making sure she'll see the dentist when she needs too. I like being able to give her the "Reach out and Read" books.

It's a privilege to be a doctor. Even an intern. It's a lot of work. People can't believe that I work 3o hour stretches without sleep. I do. It may not be the best way for the system to work, but the rewards are there, even at 3 am when you admit someone who needs you.

"the wonder that's keeping the stars apart"

Trusting to the Cat Burn

This is a rant. Consider yourself warned.

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The cat has struck again. He keeps pooping on the floor by the back door. It is absolutely disgusting. I'm often tempted to let him out to play in traffic. But instead I think I'll just move and leave P. with her pooping barfing bag of hair.

Today I caught him winding up around in a circle and starting to squat (P. was in her usual place on the couch watching TV) and I ran over and yelled an him and kicked him gently. He freaked a little and ran across the room...only to have poop balls fly out of his butt and roll across the living room floor. Then he just relocated and pooped behind the coffee table anyway. UGHHGHHGH. She said something under her breath and then that he couldn't stop once he got started. Gross.

I can't even belive I live with this. Who does this? Who let's their pet get away with crap (literally) like this? Plus he pees in the same place but she never cleans that up. I've taken to just spraying the entire area with bleach in the hopes that it will cover the smell and disuade him from going there again.

And if I come home to find him and the pile of poop, I do what works with dogs and shove his nose in it and spank him and throw him in her room. He makes this whiney meowing crow as I carry him by the scruff of the neck and throw him in her room--the location of his real litter box.

When I moved in she said all the cat stuff was in her room. Maybe. All the cat stuff except him and his excrement.

Thing is, I can't afford to move very well. I hate that. You'd think with the amount of time that I work I'd at least be able to live somewhere free of cat poop.

And so, I will make it so, Number One. Make it so.

Plus she has her friend's stuff all over the living room. I just stay in my room most of the time.

She told me that the rent was going up by $40 each, however when I called the leasing office, they said the rent's going up by $35 total. Fishy.

I have a problem with confrontation, though. I hate conflict where I live--or anywhere. I need a sanctuary. I will avoid it to the point that people start to take advantage of me. Once I realize it I get angry and hurt because they are things that I would never conceive of doing to someone else. I come back to the choice of trusting too much vs being suspicous of everything. I'd rather trust too much and get burned sometimes. It's just not fun in the middle of the burn.

Wednesday, February 07, 2007


These 5000 year old skeletons were found embracing in Italy just south of Verona, the place where Shakespeare set "Romeo and Juliet." They are young, according to their teeth, and most likely a man and a woman, or rather, a boy and a girl.

"Luca Bondioli, an anthropologist at Rome's National Prehistoric and Ethnographic Museum, said double prehistoric burials are rare — especially in such a pose — but some have been found holding hands or having other contact.

The find has "more of an emotional than a scientific value." But it does highlight how the relationship people have with each other and with death has not changed much from the period in which humanity first settled in villages and learning to farm and tame animals, he said.

"The Neolithic is a very formative period for our society," he said. "It was when the roots of our religious sentiment were formed."

The two bodies, which cuddle closely while facing each other on their sides, were probably buried at the same time, possibly an indication of sudden and tragic death, Bondioli said."

The story and article strike a cord with me today as I was thinking about "forevers" on my way to clinic. What is "forever" really? Is it a moment? A year? A feeling? A concept? Because we can no more touch "forever" than we can touch "faith." But in the same way, do we believe in it for it to exist?

I used to be very uncomfortable when my first boyfriend would talk about he and I together "forever." I could not see that far ahead of me. And even if I could I wasn't sure that he would be there. Then we broke up and I wanted the security of his forever. I wanted to know and trust that something would be there for me always. And since then I've been looking for that, thinking I found it once again, fighting for it tooth and nail, only to have to let it go again.

And today on the way home, I was thinking about my parents again. They were supposed to last forever. My mom signed the "dissolution" papers today. I asked her what that is "divorce papers," she texted back. So in six months their forever will be finalized, too.

So I thought to myself, as I drove toward the sun setting over the ocean, "Maybe the problem is with the expectation of forever. If I let that go and enjoy the moments that may or may not someday accumulate into my own piece of forever, maybe it will be here before I know it. And maybe the moments will be more beautiful because they aren't expected to add up to more than they are individually. Let each moment be its own." Because it is always only ever now.

It sounds good--that letting go of the foreverness of things. Relationships specifically. It's probably harder to do than it is to think about. Because when it comes right down to it, I still want someone to be there for me at the end of the day, every day. The same person. Not a skeleton, but a living breathing person who I love and who loves me back. They don't have to love me forever, just for all the moments we have together, however many that will be.

My classmate who died in her call room at work in November had a brand new husband; they'd been together for 10 years before they got married. He is devestated by her death, "She was my best friend and we shared a love that most people will never experience." What he thought was forever is over already.

Is that the thing about forever? You can't predict when it will end? My parents' forever seems to now be over, too. But they had some good moments--at least I like to think they did. And they think they did also. It's just hard when forever ends.

If I can let go of the concept of my forever, will it be easier if it ends?

Look at what the world is now calling "lovers" buried together in Italy. Is that forever? Or did they die too young to get there? The person who sent it too me says the lesson is that all the bad things don't endure but the love does. But the forever is in the moments--some good, some bad.

I want to think that love endures. I want to think that this couple is somewhere under the construction site where they were found. I want to think they believed in forever at the moment of their death.

"All relationships end," a friend in college told me that originally, and S. told it to me again recently, meaning that they either break up in life, or one of the couple dies. "Unless they die at the same moment," I replied.

Unless they live and love together and are buried in an embrace for 5000 years.

At this moment, I believe in forever.

Friday, February 02, 2007


I am ridiculously happy on pediatrics. Even with repetitive well child checks. Even with five million reassurances that it's just viral. Even on the last two days on wards.

I think that it is just so much better by comparison. And everyone's happy. The nurses are pleasant. They pronounce my name right. Even when my resident says she's in a foul mood she has a smile on her face. She is good with the patients. She lets me do family centered rounds. I feel like I know what's going on with my patients. Not completely left out of the loop and like I'm constantly chasing my tail to figure out what's going on.

Plus the kids are cute. I mean really. Last night the cross cover resident had to listen to the lungs of one of my patients. He's almost three years old and he was squirming all over. "Are you workin' on a poop?" she asked. "Yep," he replied. "Do you want me to change you?" his mom asks. "No, I'm alright." Okay then. So the resident leans over to listen to his asthmatic end expiratory wheezy lungs and he reaches up and touches her nose, "Got your nose!" How adorable is that?

Adults never do that. In fact sometimes I catch myself asking them how their tummy feels and get funny looks like I'm crazy.

One of my gastroenteritis patients came into clinic the other day and he was 9-ish and at that embarassed stage about his diarrhea. So I got to tell him my new favorite joke:

What has two grey legs and two brown legs?

An elephant with diarrhea.

He was cooly amused, as was his mom and sister. But she felt left out so I had to tell a joke to her, too:

What did one wall say to the other?

Meet ya at the corner.

I'm not sure she thought it was very funny. But I did.

I didn't think they were quite up for the slightly more mature one that I'd also learned:

What do you call a dog missing both hind legs who has steel balls?