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.