birth control in the water anyone?

I discharged a patient this afternoon with a newly diagnosed feeding disorder. He has poor oral motor skills, gets most of his nutrition through his abdominal feeding tube, and can only eat pureed and soft foods like oatmeal and baby food by mouth.

I was warned ahead of time by social work that the mother is slightly "limited" so I sat down with her and spent a good 15-20 minutes explaining why her child had trouble chewing and going through lists of foods that would be good or bad for him. "His mouth works like a baby's mouth so he can only have very mushy foods like a baby would eat."

Mom seemed to get it. I sent our dietician and nurse practicioner to spend some more time, help her come up with a meal plan, and make sure she understood. I went to see another patient for a few minutes and then returned with the staff physician to complete the discharge.

"I hear you've been learning about the right kinds of foods for Chase to eat. What do you think you'll feed him when you get home?" Asked my staff.

Mom thought about it for a second. "Pizza."

::headdesk::

Sensing our mild disapproval she tried again, "Peanut butter and jelly sandwich?" . . . "Chicken?"

His discharge form now reads, in capital letters: CHASE MAY ONLY EAT PUDDING OR YOGURT. CHASE MAY NOT EAT ANY FOOD THAT IS NOT PUDDING OR YOGURT. NO PIZZA. NO CHICKEN. NO SANDWICHES. ONLY PUDDING OR YOGURT.

::Sigh:: Sometimes. . .

sounds valid to me

I got called down to a patient's room around 3pm. The nurse cornered me in the hallway. Mom was discharged hours ago but she's refusing to leave now.

I enter the room and am greeted by the healthiest looking three year old in the entire hospital. . . and mom.

"Hi mom. I've read through the chart and it looks like little Manhattan has been eating and drinking well for two days, hasn't had a fever in three days, has no new symptoms, and was cleared for discharge this morning. What's concerning you?"

"Well "doctor" (spoken in that way that makes it sound like there are quotes around it), I told the nurse and the doctors this morning that her poop smells different today than it ever has before. They seem to think it's okay to just send her home when something is clearly wrong with her poop. I mean, the doctors didn't even look at it!"

After an agonizing 35 minutes during which I, yes, examined the poop in question (it was poop)and offered mom multitudes of perfectly reasonable and not at all alarming explanations for poop changes (getting older, changes in diet, recent illness, new medications. . .) , well, little Manhattan ended up being readmitted for the night.

For smelly poop.

(Bonus points for taxpayers when the child picks up H1N1 during her extra overnight stay and ends up staying another week).

We all win.

Not quite clear on the whole "baby" concept yet?

Chief complaint of the day

"Good morning! Why did you bring your 4 day old in to be seen today?"

"Well, he sleeps all the time. Like even in the day. But then he wakes up in the night.
Oh. And he cries a lot."

Oh did I mention?

I carry two pagers at night.

One is good and one is evil.

Good pager pertains to my actual patients. This pager is for good phone calls:

"Hi Dr. S! Don't wake up. I'm so sorry to bother you again. Patient A has a fever, she looks fine, you don't have to come examine her. I've already given tylenol from your orders and was wondering if I can get a verbal order to give x mg of motrin in four hours so I don't have to bother you again. Yay thanks!"

Evil pager pertains to the 50 odd patients I possess only one sentence of information about: Ashley is a 4 year old here with acute renal failure, chronic lung disease, recent head trauma, a UTI, and the flu. She'll be fine overnight! They won't call about her!

These are my cross-cover patients, the patients on all the other teams that I do my best not to break overnight.

Occasionally evil pager will yield an actual medical problem with one of these cross-cover patients. Then I'll go see them, read through their chart, talk to the parents, and try to patch them together well enough that they'll make it to the morning. These are not the evil calls.

Unfortunately these are not the majority of calls evil pager produces.

Here are some typical evil-pager calls (always between 2:30 and 5:30 am)

"Hi Dr! I was bored and looking through the chart and I noticed that this patient you've never heard of has an old prescription for antibiotics that they're not getting anymore that wasn't cancelled. Can you come look at the chart and then call pharmacy and figure out why the order is still in there?"

"Heeeey, I'm taking care of random-completely-healthy-baby-who's-ready-to-be-discharged-tomorrow-and-who-you-know-nothing-about. I noticed that on his eating schedule he's supposed to get a feed at 4am and I was just thinking that it would be nice if mom could sleep a little later. Can you come down, calculate his calorie needs, and see if you can rearrange his feeding schedule?"

"Yeah, I was just looking through the orders from today on extremely-complicated-patient-you've-never-laid-eyes-on and I'm not quite sure why he's scheduled to get x treatment tomorrow night instead of y treatment. Can you talk me through the team's reasoning? And then can you come talk to the patient's mom about it? Also, he doesn't feel like eating right now, can you convert his list of 24 rare medications you've never heard of from oral to IV."

Or the very very very very worst:

"I have call orders to let you know about a heart rate over 150. It isn't 150, it's actually 134, I just thought I should let you know."

Thanks.

The call room we theoretically sleep in while on call is located at the end of a long long white hallway, which for some reason evokes The Shining and seems to lengthen exponentially as the night evolves. Around 1am, this hallway feels completely interminable and the call room starts to feel like some mirage of a desert oasis. Whenever, miraculously, I find that I'm caught up on my charting and I've seen all the patients on my list, I amble towards the 2 south side of the hospital (very casually, and by a different path every time, I don't want to alert the pager-gods to the fact that I am actually thinking about sleeping. This ires them). Once I reach the end of that hallway, I accelerate into a full-on power walk, and now it is simply a race to reach the room, kick of my clogs, and climb into bed for a glorious 5 - 15 minutes until the pager goes off again.

Sometimes, just to tease me, the page comes the second I turn the light off. 99% of the time I don't even make it past the doorway.

If the stars align and I actually have a 30 - 45 minute break, the pager gods watching over the other residents in the call-suite will make sure that every single other beeper in the suite is set to maximum volume, goes off every 5 minutes, and that the resident-owner of that pager will have the slowest beep-silencing reflexes of all time. As well as the loudest possible telephone voice. They also arrange it so that every single door of the suite slams when you go through it, no matter how gently.

Hmmm. . . .

I speak in love

You must understand that I was one of the most nervous third year medical students of all time. It's terrifying when you're suddenly thrust out of the warm, comfortable womb of classroom case studies into the harsh glaring lights of an actual hospital with actual real live patients who they are actually going to let you touch and possibly break.

But the boy student sets all new standards for not quite ready to cut the cord.

It turns out that his first day choice to awkwardly orbit within five feet of me at all times was actually the best case scenario as I was paged by not one, but three, charge nurses in the afternoon after I sent the boy one across the hall to get a chart(literally open the door, turn right, chart rack).

"Hi, I'm calling from PICU south/infant unit 3/2b (which are literally on completely different floors on opposite sides of the hospital), I have your medical student here, he's lost and he's not sure how to find you."

For some reason, once lost, he decided the best way to proceed would be to leave the unit and ascend stairs.

Poor lost duckie.

And I've arrived

So the day has come!

I showed up yesterday morning for more baby plumping fun and got the following 911 page:

"Scopes, go pick up your medical students from the lounge, they don't know where to go."

Yes, loves, I have my very own bright eyed nervous-as-all-get-out third year of medical school ducklings to do whatever I please with for the next three weeks.

No matter what project I assign them, they manage to do it while nervously fluttering around exactly three feet behind me and two feet to either side. Everywhere I go they're there, looking at me expectantly. "Teach me," plead their eyes, "And please please please assign me a project I can successfully accomplish without injuring anyone or passing out."

The girl one (I-have-a-phd-I'm-a-doctor-and-a-half!) is picking things up relatively well, and spends her down time at least pretending to research stuff or work on her notes. The boy one (it's-wildly-unclear-how-I-got-into-medical-school-to-start-with-and-please-don't-count-on-me-to-help-you-with-any-phone-calls-because-I-will-forget-my-name-panic-and-hand-the-phone-to-you) is having a tough time.

The following breathless page is not atypical (approximately 35 minutes after I sent him to another ward to check if a patient's surgical scar is healing well).

"Hi, Dr. S. I got to the patient's room. What should I do now?"

Well, try looking in the room and seeing if the patient is there or not.

"Um. ::agonizing 27 second pause:: The curtain is closed. I can't tell."

Love, you are now a student doctor. You may enter the room and look inside the curtain, then check the scar site for redness, tenderness, pus, and make sure it's well-aligned.

::50 minutes later, back at the work room.::

"Okay, she's there, I looked at her and she looks fine. Her pupils are equal and reactive to light, she has reflexes present in both kness, I can't tell if she has a murmur or not. . ."

::I interrupt:: Butterfly, sweetheart, what did the incision site look like?

"Oh. The incision?? The incision. Oh yeah! The incision. I didn't check."

Repeat times 80 times a day.

Feed the babies

I'm currently working on one of the developmental pediatrics wards. Most of our patients are teeny little "failure to thrive" babies (below 3rd percentile for weight). I spent most of the first week frantically ordering genetic testing, swallow studies, abdominal x-rays, examining poops (how much of my day is spent talking about poops? Oh, about 97.3% of it.) . Basically looking for any reason these little button bbs are remaining little tiny button bbs.

(Is there anything sadder than a skinny baby?).

So my staff put up with all my nonsense for about three days and then, in the middle of yet another description of various surgery consults I want to order to evaluate ye randome rare GI condition by biopsy, she stops me.

"Scopes."

I look up.

"If you feed them, they will grow."

Important

Presenter at morning conference: "I couldn't find a good visual representing appropriate post-drowning CPR, but I thought this was actually pretty close."

True EMS presentation

Winter.

"Two sisters, 13 and 15, were drinking in the backyard when one fell into their swimming pool. The other jumped in to rescue her sister, but was unable to get her out of the pool.

Their mother, also drunk, came outside to look for the girls and fell into the pool. EMS was involved when a neighbor called police to file a noise complaint against the family.

The good news is that the alcohol-induced vasodilation allowed them to cool so quickly, they were all able to be resuscitated when rewarmed."

Yay!