peds


I had been congratulating myself, at the children’s hospital, on not having to deal with much in the way of bad news. Sure, we were consulted a lot to help with cancer patients; but usually by the time we turned up, the parents had gotten the news from another service. Many parents also seemed to receive the news of appendicitis as though it were bad, too. I guess the idea of your child needing surgery at all has to be a bit of a shock. To us, though, the fact that it wasn’t lifethreatening, wasn’t cancer, and had been diagnosed appropriately seemed so good that it was sometimes hard to stay on the same page as the parents. Nevertheless, though not quite as routine for the family as it was for us, appendicitis is a widely known and accepted fact of life.

The last night, though, was not so simple. The young parents had brought in their six-month-old daughter after she’d been fussy for three days, not eating properly, and then over the last 12 hours seemed especially fussy about her belly. When she started passing bloody stools in the ER, the diagnosis was obvious, and was quickly confirmed with ultrasound: she had an intussusception. (Which is where one segment of the intestine telescopes inside the next segment, producing swelling and eventual ischemia, if not corrected.)

The classic treatment is an air or barium enema, which both provides a definitive diagnosis, and is usually successful in reducing the intussusception. This time it wasn’t. The radiologists tried all their tricks, and were unable to undo the intussusception.

I was around watching, because the usual procedure is for surgery to admit the child for observation after radiology fixes the problem, as it recurs 15% of the time. When the radiologists announced that it wouldn’t be safe for them to try anything else, I started making calls. It was great timing, from our perspective, because the OR was just finishing up with another case. So the staff were on hand, and with 20 or 30 minutes of turn-around time, they would be all ready to go.

Which meant I had five minutes to explain to the parents that a relatively simple problem with a minimally invasive solution had just become a lot more serious, and now needed a very invasive treatment. Because we didn’t know how much of the intestine would have been damaged, the OR consent had to include possible bowel resection and even stoma formation. That’s a lot for young parents to deal with in a few minutes.

They seemed very close, and mostly held on to each other and their daughter while we set things up. I went back a couple times to ask if they had any questions, but I think they were too shocked to say much (or perhaps my first explanation had been so lucid that it left nothing else to be desired!).

The night had a happy conclusion, because the attending and fellow were able to release the intussusception pretty easily, and nothing else had to be done. We were all pleasantly relieved, as the length of the child’s symptoms had been worrisome. (Most children with this problem are sick enough to come to the hospital within 8-12 hours of it developing.)

One good thing about the childrens’ hospital is the babies. I finally found a baby yesterday who 1)didn’t have any monitors attached, meaning she could be moved away from her bed 2)didn’t have any parents handy who wanted to cuddle with her themselves 3)hated her crib, and loved sitting on someone’s lap. The attendings who walked through the workroom while I was holding her and explaining my TPN calculations in babytalk raised an eyebrow or two. I also took her on some errands around the hospital with me; amazing how everyone’s face lights up, and they’re so happy to help, when you’re holding a cute baby (blue eyes, blond hair, pink cheeks – adorable). . . Unfortunately for me (good for her) she was discharged the afternoon after I met her. I had been looking forward to playing with her some more; but TPN does go faster without a baby crumpling your papers.

I just realized the last month and a half have involved no end-of-life discussions whatsoever. Is it bad to miss that, along with everything else I do at my own hospital? Not really miss, so to say, but notice the absence of. . .

Two more days at this hospital; only two days to go. . . The sky looks brighter already, and I’m developing the most discreditable devil-may-care attitude about what anyone at the hospital thinks of me (thus, playing with babies in the workroom in the middle of the morning; expected perhaps of peds residents, but not of surgery residents).

Ok, I’m back online. This rotation is nearly over, which is a good thing, because honestly I’m more depressed, miserable, and angry than I’ve been in residency so far (except maybe on trauma; and that was made more tolerable by having friends around, residents and nurses I knew and trusted). Now I’m trying to figure out what to say when I get back “home,” because several of the residents were teasing me that I’m so optimistic, but the peds rotation would destroy me. They were mostly right; I’m just hoping it’s not permanent; and I don’t want to admit it to them. There were three rotations of second year that I knew would be absolutely horrible; one down (almost), two to go.

Anyway, I’ve been remembering the things that made me go into surgery in the first place (a decision that I’m not up to defending right now, just hoping I’ll feel better about it once I get away from this place). One particular story I remember because at this hospital we had a child develop a wound dehiscence after an abdominal surgery. Supposed to be pretty rare in kids, and the M&M on the subject was protracted, to say the least. A dehiscence is when the fascia (not just the skin) comes upon. There are two main reasons: you didn’t sew it properly to start with, or the patient’s tissue, for various reasons (debilitation, radiation, steroids, infection, to name a few), is so weak that it simply doesn’t hold even the best suturing.

I was on call on ob/gyn, and in between the deliveries and an ectopic pregnancy case, the team got called about a patient in the ER. She’d had an abdominal hysterectomy about a week previously, and had gone home shortly afterwards, apparently healing well. She dehisced at home, fortunately only to a minor degree, and came in to the hospital. As a medical student, of course I was fascinated, and tagged along the whole way; but I was also frustrated by the OBs’ response. The intern went and looked, and paged the senior; he went and looked, and called the attending. She didn’t believe him, and went to look too. At that point they agreed that they supposed it was a dehiscence, and called the surgeons to ask for advice.

I’ll never forget the surgery intern (who was after all tall, handsome, clever, and only not cocky because he was smart enough to warrant his own confidence). He strolled in, looked at the wound briefly, and remarked, “Yes, it is dehisced, sure enough. You’re taking her to the OR, right? You don’t need us for anything, do you?” The OB attending agreed that this was her plan, but insisted that the intern bring his senior, and even the surgery attending, in to look at things in the OR. Her explanation also sticks in my mind: “I never saw anything like this, even in residency. I’m not sure what to do with it. And maybe we ought to run the bowel [surgical speak for starting at one end of the small intestine and looking carefully till you get to the other end, to make sure there are no injuries or other anormalities], and I forget how to do that.” So the attending surgeon, being dragged out of a sound sleep (they were required to take in-house call, but counted on the seniors to shield them from any disturbance except a trauma requiring a laparotomy), came in to the OR and explained to the OBs that when the fascia comes apart – you should sew it together again. The end. And if you want to run the bowel – you start . . . at one end. . . and proceed . . . to the other end.

I’m not trying to make fun of the OBs, because they were overall good at what they did (that attending was one of the weakest), and I understand that dehiscences would be much rarer in a population of relatively healthy women (overall younger than the general surgery population) having elective hysterectomies. But to a medical student, it was noteworthy. Even then, several months before I did my surgery rotation, and got swept off my feet, I started to think that I’d rather be sure of the basics.

I still hate this rotation. But I expect I would have found at least one occasion to be equally miserable if I were doing ob/gyn, as I originally planned.

I ought to tell another story, where the joke is on us. We had a pregnant woman staying with her sick child at the hospital. One evening, the nurses called the fellow in a bit of excitement: the mother was having contractions, with increasing frequency. He ran upstairs, and became quite excited himself, and eventually with great commotion hustled the lady off to an adult hospital with an OB ward. Myself, I regarded it as less of a problem. First, unlike the fellow, I’d known she was pregnant prior to that night (just by looking; I guess he didn’t notice). Secondly, I considered that with her contractions still 8-10 minutes apart, she was unlikely to deliver within half an hour, which was plenty of time to arrange transfer (second pregnancy; maybe I was being too pessimistic). Thirdly, I privately thought it would tremendous if we did have to assist with the delivery after all. Of course, that was the thought that was really upsetting the fellow.

By the end of the last call, I was having fun. I’d jokingly protested at the ER residents every time they called me with appendicitis in a teenager for the last several days (for surgery residents’ purposes, we only get credit for ‘pediatric’ cases if the patient is under 12; so, although all the surrounding surgeons and anesthesiologists refuse to touch a patient under 16, often 18, and send all the teenagers with appendicitis to the children’s hospital, my paperwork doesn’t benefit unless some actual children have appendicitis), and nearly had them believing that I had single-handedly effected a policy change, ie surgery residents would no longer come to see teenagers.

Finally, they called me about a nine year old. Only one day’s worth of symptoms. I wasn’t expecting much, hearing the story from the ER, but when I touched the child, she had peritonitis.

One thing I have learned from this rotation is the amazing range of variation in appendicitis. Some children will show up after one day and be perforated; others will show up after a week, and still be well enough that you can’t be sure they have it. Some will have a normal white count, others will be in the 20s or higher. Some fevers, some not; some throwing up, some not. The physical exam seems to be the most reliable indicator (short of a CT, and the attendings at this hospital are great ones for discarding that security blanket), but even then there will be a lot of discussion: the ER doctors, the junior residents, the fellows, the surgery attendings – all will have a different impression of just how bad the child is. Sometimes I call it, the fellow says no, and a CT or an overnight observation proves me right; more often, the other way round. Sometimes the attending decides to go to the OR, despite nobody else on the team being impressed, and they’re right.

Last night, I knew the girl had appendicitis. It felt exactly right; the white count was up, but not so high as to look viral; low grade fever, again not high enough to point to a virus. Everyone else was busy (or sleeping; hard to tell which when they don’t answer pages), and I couldn’t get any seniors to confirm my conclusion. (Another frustrating thing about this hospital is the lack of confidence placed in the junior residents. My place on the team is interchangeable with an intern. At my own hospital, I can take all the surgery calls all night, run the surgery ICUs, and book multiple ORs by myself; the attendings take my word for it. The pressure is high, but I’ve gotten used to it; I expect it. Here, I can swear up and down that a child needs to be in the OR (or that they’re ok and should be fed), and almost no one will let me act on my diagnoses.) So after an hour I said forget about fellows and attendings; admitted the child, started antibiotics, and called the OR. I even gave her a good dose of morphine, and crossed my fingers that the oft-repeated adage that narcotics can’t mask peritonitis would come through for me.

It did. When a fellow finally got around to see the patient, he was adequately impressed, and confirmed my plans. Then I got to do the case myself. The attending was kidding me the whole way in: “You think this kid has it? She really has it? What makes you think that? Fever? That’s nothing. What’s the white count? Don’t you think that’s a little high? Only had symptoms for one day? Come on; she gets on operation after one day?” So of course that made it extra fun when we found purulent fluid in the pelvis. The attending was one of the nice ones, who let me do every single step even when it took a minute longer. (Perhaps nice is not the word for it. Really it’s a matter of confidence: he knew he was good enough that he could afford to let me go slowly. It’s the attendings who don’t have the skills themselves, who aren’t confident enough to push the residents forward.)

After all, it was nothing much, an everyday occurrence: a child with appendicitis, an uneventful surgery. But I was there the whole way through, and I felt as though I was managing it myself. Very satisfying.

One of the ER bloggers a while back mentioned something about “knowing how to talk to surgeons on the phone,” and I didn’t know what he was talking about. I do now.

There is nothing more annoying, in the middle of the night (or a busy day), than to get an ER doctor trying to give you a five-minute presentation on a patient. I really do not care what time the patient went to the outside hospital, or how exactly they got transferred here; unless the creatinine is 3, I don’t care what the chemistry shows; unless you have a positive urinalysis, and are apologizing for calling me anyway, I don’t care what the urinalysis showed (yes, sterile pyuria – white cells and no bacteria – can help confirm a diagnosis of appendicitis; on the phone, I still don’t care); unless you got a CT scan without asking us (which would be ok, if it shows appendicitis), I don’t care if you got xrays on a patient whom you think has appendicitis; I also do not care which ADHD and asthma meds the kid is on (unless they include high-dose oral steroids); I don’t care whether (when calling for appendicitis), you think the abdomen is distended or not, or whether Rovsing’s sign is positive or negative. All I really want to know is, what room is the patient in, and a name or medical record number, so I can track them down when they change rooms. Apart from that, you can be as impressed as you like by the abdominal exam; you could think they have peritonitis. I don’t care, I have to touch it for myself, and until you give me a room number I can’t do that! (At my own hospital, about half the ER residents, I would care what they think about whether the patient is truly surgical or not; here, I haven’t had time to learn to trust the ER staff, so. . . I don’t care whether they think there’s rebound or not.)

Bottom line: you called the surgeons because you want us to touch the patient. So give me the location of the pain, and the location of the patient, and stop talking. The best calls are from the male PAs, who usually are not too chatty: name, age, medical record number, chief complaint, white count, “I think it’s real” or “I’m not sure, just come see.” End of conversation.

Unfortunately, I don’t know a polite way to say that to attendings, fellows, or residents I don’t know (ie the entire ER staff at the children’s hospital),  so I get very frustrated at night.

I’m also puzzled by this: the surgery resident’s ethos puts a lot of stock in instant response: if you call me with a consult, I will be there in five minutes if I’m not doing something important; and if I’m in the OR, I will be there five minutes after the end of the case. (And if the nurses call, I will address their concern immediately if it’s urgent, or as soon as it comes up on my triage list otherwise.) In fact, sometimes it’s the only thing that keeps me going at night: I can’t think straight, I’m not sure which elevator goes where, or what floor I’m on or am trying to get to, but I will be in the ER two minutes after getting called. So why do the ER people call, then act surprised when I show up? Or why do the general peds teams call us at night with a consult “for you to see in the morning”? If you call me now, I will see it now; I will not save work for the morning. If you don’t want the patient and family woken up at 11pm, don’t call me at 11pm. (I know some residents aren’t like this, but it’s not just me, because I learned this from the chiefs getting angry at me if I wasn’t ready to report on a consult within ten minutes of getting the call, or the first time they heard about it, whichever came sooner.)

Ok, I’ll stop being grouchy now. I hope I have any personality left at all when I get away from this hospital.

I feel sorry for the OR team that got stuck working the same night with me. We had a case of perforated appendicitis, the kind where you start regretting the decision to operate the minute pus starts oozing out of the first incision. (Note to ER doctors: unless the patient has a creatinine of 3 [indicating real renal failure] never ever ever do a CT scan without iv contrast (ok, unless you’re looking for kidney stones); and there is literally no excuse in the world for not giving oral contrast to a patient over the age of reason – appropriate use of antiemetics should enable the patient to get at least a modicum of the contrast down, and some is better than none. For the non-medical readers, iv contrast is invaluable for demarcating abscesses, which are characterized by a vascularized wall, and no blood flow inside. It also helps to diagnose dozens of other surgical conditions, including mesenteric ischemia, ischemic gut, and small bowel obstructions which need an urgent operation (as opposed to the ones that can wait). Oral contrast is necessary to show which round objects are intestine, and which could be something else, like an inflamed appendix or an abscess. Not having contrast is like trying to peel potatoes in the dark – a waste of time and radiation.) (Note to self: next time, when the patient has diffuse peritonitis on exam, you should ignore the worthless noncontrast CT scan which may or may not show an abscess, and go with your clinical diagnosis of a perforation that’s had time to spread.)

(Appendicitis complicated by perforation and an abscess ought to be treated nonoperatively, because surgery is too difficult and risky in that setting. Like many other medical pearls, I didn’t quite believe that one until I proved it for myself. Someday, I’ll stop reinventing the wheel.)

It’s not that I did the case badly, just very very slowly. I’m doing better at getting the laparoscopic instruments where I want them to go, but things take twice as long when I drop everything I pick up, and have to grab it again and again before I get a grasp that works. However, as the attending observed, since there was already pus everywhere, things could hardly get any worse. . .

Better luck the next night, I guess.

It’s a good thing I have to admit so many kids with appendicitis and non-appendicitis, because I need more work on laparoscopic appendectomies.

This became abundantly clear last night when, two-thirds of the way through a case, the attending commented, “Do they do laparoscopic appendectomies at your hospital?”

“Well, yes sir, they do, but I haven’t gotten to do any there yet.” [so the fact that I seem to have two left hands is really not my program's fault] 

The appendix being at the other hand of the abdomen from the stomach and gallbladder, which is what I’ve mostly worked on (or tried to) laparoscopically, appendectomies feel like working upside down and backwards – and it shows in my random sweeps which usually don’t even get my instrument onto the screen, let alone do anything helpful to peel back the inflamed tissue and expose the parts that we need to be working on.

Another call night is over. Overnight call really isn’t that bad. There are only a few parts that are nearly unbearable: The ER calling two minutes after you lie down, to ask you to see a patient whose chief complaint you’d noticed in the computer hours earlier, and have been asking repeatedly whether they’re sure they really wouldn’t like you to consult. They keep saying no, it doesn’t seem surgical, we’ll handle it; and the minute you finish every other piece of work in the house, and finally get up to the call room, then they call. Or the nurses, who seem to have arranged to save all their concerns all night for that moment when I’ve calculated that if I start right now, I can maximize the last fifteen minutes’ nap, and still get all the scutwork done before rounds. But instead I have to run around and take care of all the low urine outputs, uncontrolled pain, inconsolable parents, and dangerous vital signs which somehow weren’t worth calling about (or mentioning, when asked if there were any problems) till right before rounds. That’s when I lose it completely – internally; externally I think I’m just moderately grumpy, but mostly polite still.

Those moments, and then that one hour of rounds, when a night without sleep adds up to make every single statement by anyone so gratingly annoying that it’s all I can do to keep from screaming. After about one hour, the routine kicks in, and being still awake seems normal. For that hour, I try not to talk, and people just assume I’m tired. . . I guess I am, but I perceive it as frustration, not tiredness.

And after all, it’s not so bad. I met a lot of nice families, and even more nice children with hopelessly irresponsible parents. I got to cuddle with a neglected baby (neglected by its parents, not the nurses). I got to explore most of the possible variations on “right lower quadrant pain, not appendicitis.” (And also work on my ability to make diagnostic/therapeutic decisions regardless of my personal desire to do another appendectomy. Don’t worry, the senior levels did not want to do a case, and their judgment was better than mine.)

Q3 call makes the month go fast. The days run into each other. I only have to wake up and drive in to work once, and it makes two days go by.

Peds is good. The babies are cute. Actually, this is a problem on rounds, because I would rather play with the babies than pay attention to the details of calculating their feedings or TPN orders.

The anesthesia part is amazing. Anesthesia for these tiny babies is incredibly delicate. The ET tubes for the smallest babies are about the size of an adult venous introducer. . . And for the older children, the finesse with which the anesthesiologists talk them into staying calm during the trip back to the OR (admittedly, with the help of versed) is impressive. For adults, induction of anesthesia is usually performed with an iv agent – quick. For kids, though, they avoid putting in an iv until they already  have them asleep with an inhalational agent – which means they have to be bagged the whole time an iv is being found on their tiny hands or arms.

Not to mention the matter of waking up: In adults, you like to get some definite responses to commands before actually pulling the tube out. For kids, there’s no way they’re going to do anything coherent while still coming out of anesthesia, so the anesthesiologists have to just pick a moment when they think the child is awake enough, and doing some spontaneous respiration, to pull the tube out, and wait to see what happens. After all, they’re small, and easy to ventilate by hand if they need a few more minutes to wake up. (Some anesthesiologist will no doubt come by and explain that there’s a lot more detailed calculation involved. Either way, I’m impressed.)

The children’s hospital is not as bad as rumor painted it (although their computer system is strictly for the birds). There’s something to be said for having so many senior residents and fellows around that I am only responsible for floor patients – and I am by now very efficient at handling a large floor service.

It’s also fun to see entities which were previously the stuff of [textbook] legend showing up as large as life: gastroschisis, malrotation, intussusception, Meckel’s diverticulum - and lots of classic appendicitis. (Which is especially fun, because in pediatrics you try to avoid radiation as much as possible, so almost none of these kids get CT scans. Diagnosis and management are based on history and physical exam, with the occasional ultrasound. For a rarity, I got to book a patient for the OR simply on the basis of, “His abdomen is nearly rigid, and certainly requires urgent exploration.” No labs, no imagaing, just what my hands could tell me.)

For added fun, I stumbled across in the library (amazing how the books I like just pop up in front of me) an audio edition of Alison Weir’s Queen Isabella. Alison Weir is an English historian who writes detailed accounts of obscure medieval events, and manages to make them interesting. I first appreciated her for her defense of Richard III as innocent of the death of the Princes in the Tower (a private bias of my own; I always enjoy finding reputable evidence to support my romantic belief in Richard as hero). This book, while occupying 18 cds, and therefore valuable as promising to last for two months’s driving, seems a little biased. Admittedly, the story of Isabella (French princess, betrothed at 7, married at 12 to a homosexual 12 years older than her, she eventually ran away, took a lover, led an invasion of England, deposed (and allegedly murdered) her husband (Edward II), and ruled in her son’s name (Edward III) for years, till he came of age, killed her lover, and put her under house arrest till her death) lends itself to some feminist revision. However, the argument that we ought to regard Isabella in a better light, now that we can look back from the standpoint of modern sexual mores, seems a little weak. After all, Isabella did what she did in a society which certainly condemned adultery (especially by women, and regardless of excuses) and treason. The fact that 700 years later her behavior seems almost normal/rational/excusable doesn’t change the fact that it was wildly countercultural and dangerous at the time. Her choices were made in that setting, not under modern “enlightenment.” Nevertheless, I’m always up for a good story about international intrigue and the primal conflict between France and England (two nations that seem born to hate each other), and if Ms. Weir can stop mentioning male oppression in every other sentence (once a paragraph, perhaps?), this should be a fascinating book.

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