Adult critical care vs. Pediatrics

Two not-so-exaggerated interactions.

Peds clinic (after 4 minutes with the patient):

Me:

"Patient Baby is a healthy one year old who presents with a birthmark on his head that has been previously diagnosed as a sebaceous nevus by two pediatric dermatologists who recommend removal between age 8-11.

My assessment is that this child has a sebaceous nevus that should be removed sometime before adolescence."

Staff pediatrician:

"Great job! Exactly right! I agree! Excellent presentation and clinical instincts! Woo-hoo! You've been working so hard, that's your second patient, right? Go take a coffee break."

Adult Critical Care: (after literally 12 overnight, sleepless hours of being in the patient's room every 10-15 minutes while juggling pages about literally, yes literally, 43 other critically ill patients)

Me:

"Good morning Dr. S! Patient W has significant history of every cardiac pathology imaginable (which I then listed in chronologic order including details such as systolic function, dates of hospital admissions, and cardiologists consulted) as well as end stage renal disease (presented in similar detail). He presented in vtach cardiac arrest and was found to be febrile.

I literally saved his life by performing three rounds of CPR including epinephrine, shocks, intubation, central line placement, aggressive fluid and electrolyte management, antibiotics, and blood transfusion. He proceeded to code two more times, requiring initiation of an antiarrhythmic drip, and subsequently developed pulmonary edema while remaining hypotensive, requiring a dialysis consult and initiation of pressors. I've arranged for dialysis this morning, cardiology consult, ordered all necessary labs and diagnostic testing for this morning and patient is currently clinically stable."

Staff:

"Well, doctor, (somehow impregnating a Colbert Report season's volume of sarcasm into that one word) I notice that his [random irrelevent electrolyte like manganese] was checked at oustide hospital and is slightly low. Did you miss that? Were you planning on fixing it anytime soon? And what supremely esoteric fungal infection observed only in a 1 mile subtropical region of latin America might you have considered and covered for? And what is his exact troponin level to the third decimal point. . . .? "

Me: [reflexes are slow at hour 29 awake] ::long pause::

Staff: I highly suggest, doctor, that you know your patients before presenting them. Now why don't you get to work at fixing this? ::walk away::


I'm currently on the peds side, by the way, and going through pretty significant negative reinforcement withdrawal. I keep waiting to get yelled at and it keeps not happening. Makes me nervous.

Oh and did I mention

Dr. S actually laughs with the sound "Mwa ha ha ha ha." (This laughter is usually occurring at the expense of someone else, most likely a patient). It bears a striking resemblance the count on sesame street mixed with the evil witch of west but with about 71% more evil. Bone chilling.

So appreciated

7:01am

Dr. S: Why is [other resident] not here yet?
Me: She's across the street at Starbucks, it was her birthday yesterday, she's probably a little tired.
Dr. S: She didn't mention her birthday yesterday. Why didn't she mention that to me??
Me: [pause] . . . . .
Umm, sir, she wasn't here yesterday. It was her day off.
Dr. S: Oh. I never really notice if my interns are here or not unless I end up
having to do extra work.

Code blues and parsnips

One of my favorite on-call joys is perking up my ears while we're in the middle of a code and listening to the random sideline conversations that take place at the moment of someone's passing.

I find it both amusing, the topics that come up! and kind of touching or poignant sometimes.

Occasionally there's radio playing 80s hits at one of the nursing desks. Last night two respiratory techs were talking about the best time of year to plant parsnips. There are always a handful of nervous interns and medical students milling about, chit chatting about other patients, and secretly hoping no one asks them to do anything important.

It's just such a striking reminder that life really really goes on.

I suppose it could be seen as irreverent or disrespectful to the moment, but I kind of appreciate it. And we can't just fall apart every time a code happens, that would do a great disservice to our living patients that we'll have to get back to in a few minutes. I mean, if I was dying I sure wouldn't want every doctor in the place standing around in reverential silence. Or crying. I think I wouldn't mind so much overhearing one final conversation about parsnips.

An actual lecture slide today

Strongyloides geographic distribution

-Developing countries
-Regions where fecal contamination of water is prevalent
-Kentucky


p.s. Hundreds of these buggers were found inside one of my patients! Neato!

Wishful thinking

Dr. S: "I've had a headache since you presented your first patient this morning."

Optimistic me: "Have you just realized how much you're going to miss me next week?"

Dr. S: "No." the look I really don't think that's it at all."


I tried.

not quite getting it

I just discharged a youngish man who had literally been without a heartbeat for about 20 minutes by the time he was admitted to me.

This was one week after his first heart attack. He had been down for 5 minutes without a pulse before his wife remembered how to dial a telephone. Down close to 10 minutes before EMS arrived and CPR commenced.

The first five days we didn't think he would survive the day.

The next five days we didn't believe he had any real chance of meaningful neurologic recovery.

Three days after that he seemed to have some brain function but developed acute respiratory distress and we doubted we'd ever be able to get him off the vent breathing on his own.

Four days after that? Breathing tube gone, sitting up in bed, talking, no neurologic deficits whatsoever, doing pushups and situps in the bed whenever the nurse was looking the other way.

I mean, a straight up miracle.

And through it all, his wife sat at his bedside 24 hours a day, slept sitting up in a hard-backed chair, woken every hour for his vital sign checks, not leaving to eat, keeping the tv on the channels he liked, rubbing his feet and arms when they got swollen, filling out piles of insurance forms for him. She did not leave his side.

This morning I walked in and, as usual, asked if he had had any problems overnight:

"Well, I'm thinking about leaving my wife, I'm just not sure about that woman. Something shady about her."


Sometimes I give up.

Now I of all people

should know that correlation does not imply causality.

And yet these past two days, Dr. S has been downright pleasant to work with. He has even lowered himself to, heaven forbid, teaching me on a few occasions. (And not his usual "teaching" tactic which involves stonily staring at me after I make a statement until I realize my mistake, apologize, and correct it. At which point he either continues staring for a good awkward moment longer, to drive it in I guess, or has already started rounding on some other floor and is less-than-patiently waiting for me.)

Anyway, two days of puppy dogs and bunny rabbits and frolicking in the petunias, and on these two days it just so happens that I did not have any clean professional looking socks and thus opted to wear. . . a skirt.

So now I have no idea if these two seemingly random happenings, Dr. Me in a skirt + Dr. S behaving like a human being, actually have anything to do with each other. But nonetheless I need to come up with four more skirts to wear for the rest of the rotation and fingers crossed that that will be enough to carry me through Sunday when I'm on call in scrubs.

Hey, every little thing helps.

Creating rapport with patients

A master class.

Dying (and not aware of it) patient: "Dr. Saul, I hope that next time I see you it's for a round of golf."

Dr. Saul: "I sure hope not, cause the only place you're playing golf in the near future will be in heaven."

Patient: What?

Dr. Saul: Well, remember those tests we did last week? You have cancer! One of the cancer docs will be around to talk to you about it later. Bye."


Yes, for real.

My first saul-pliment!

(Dr. Saul is my oh-so-lovable senior physican this month, described in this post.)

So a usual saulpliment goes something like this:

::peering over his glasses::

"Hmm . . . you seem to have quite a rapport with the family."

This is accompanied by a suspicious squint usually reserved for someone who's just drunk a gallon of milk and then thrown it back up. Kind of vaccilating between awe and disgust. You get that look for two seconds or so then he walks off.

(Yes, he leaves me behind just about every time I step into a patient's room or pause to have a conversation with a nurse. Occasionally he actually leaves for other wings of the hospital and then I get that look again when I find him againtwenty minutes later.)

So that's the closest to positive feedback that I've gotten so far this rotation. Then, this morning, it happened.

I showed up, late of course, as he'd told me to meet him on the third floor and then booked it to the sixth floor within the 50 seconds it took me to ascend on the elevator. When I arrived, as usual he looked me up and down, but instead of the usual extra-dissaproving version of the look, he actually smiled (yikes!) and choked out, "well don't you look professional today, Dr. Scopes," awkward pause, "and you have certainly performed adequately for an intern this rotation."

I was literally in shock. I was unaware that he knew my name as he has only referred to me as "the intern." (As in "well, the intern must have forgotten to write the vent settings this morning leading to patient F's respiratory alkalosis.)

After I managed to stutter out a 'thank you,' he turned to the NP:

"Laura, make sure you write down that I gave verbal feedback and commented on the intern's professionalism."

And off he went.