Politics

It is election day!! Go vote!

But I have to say neither candidate has a really good handle on the health care issue. And just cuz health care is sorta my life I wanted to bring up some facts that we went over yesterday in class...

Why people go to the ED:
- they have a true emergency
- they are traveling to that city and get sick
- lack of alternative access: uninsured, no PCP appointment available, PCP closed
- societal outcasts: homeless, illegal immigrants,etc
- drug seekers

Average cost of an EM visit: $383
Average cost of a PCP visit: $60
(although this is not comparing apples to apples---most people who visit the ED are generally sicker, although 55% of the 90 million ED visits were deemed unnecessary in 1996)

Number uninsured:
- 47 million uninsured

Who pays for the uninsured?
- The insured. Premiums and such don't just cover the individual needs. We're all paying for everyone to get medical help. The money has to come from some where

Why is this important?
--if the insured are paying for everyone else---wouldn't we all want everyone to be insured and then no one would be paying extra??

Just some food for thought!

My Favorite Day!

It's the most wonderful time of the year!!!

Happy Halloween!

If you're looking for a spoooookkkkyy flick---try The Strangers! Its the scariest thing I've seen in a long while.

Med student informs attendings and isn't beaten down!

Being back in the ED again, and being sincerely happy about it, definitely makes me a bit more confident about the whole EM/Peds thing again--cuz I have to say---there are days that I very much miss the OR. And being on the Peds side for the past few months got me thinking that maybe Peds was more my thing, but after one shift downstairs, I realized my heart is totally into the ED thing too.

I am currently doing my first, and only, away rotation. It is pretty interesting to see how the ED works here compared to back home. Firstly, for all lacerations: the nurses numb up and scrub them out for you. This lets me get other work done like calling surgery or pediatrics, or discharging someone. Secondly, I never have to look up a single number to page someone---I just tell one of the three secretaries that I need to talk to Dr. C and they take care of it---within ten minutes I'm getting paged overhead that he is on the line waiting. Lastly, people here are ridiculously friendly.

Last night I had a sick kiddo. In the ED the main purpose is to decide who is "sick" and who is "not sick." I have to say as a second year I thought everyone was considered "sick"---I mean why else would they have gone to the ED?? Now I think I finally have it down. So this kidddo had a fever of 104, hadn't eaten/drank anything all day, was tachycardic and tachypnic and just looked out of it. I was worried. So we started an IV, got cultures from her urine and blood and gave her Tylenol and Motrin. She perked up after the second bolus and I felt much better. Her urine came back with a UTI and we decided we were gonna send her home, but my attending really wanted me to talk to her pediatrician prior to sending her home. Of course the parents had no idea which Dr. F it was in town (there were 3 by the same last name) so I had to do some serious searching.

Around 10:30pm I was pretty sure that I narrowed it down to the correct doc. I was nervous to page this doc late at night just to do a "let you know" conversation, but it was important. So I dialed away. She responded about 10 minutes later and was amazing. She was completely appreciative that I informed her. I couldn't believe it. I hung up the phone with a smile on my face. And that's when I started thinking---I hadn't called a single consult so far that resulted in someone getting nasty or being rude---people here were happy to help out! What an amazing concept---we were all on the same side --trying to do best by the patient. And that's when I started thinking, maybe I could live here.

tying up the PICU

I finished my rotation and at PICU--- I know I didn't report much on it, ok like nothing really on it, so I am gonna sum it up here!

It was intense. And as a close peds mentor told me---you have to be deranged to like it.
Call me deranged!

Because I liked it enough that I actually applied to a pediatric program. Who woulda thought?!?! I was able to cardiovert a stable arrhythmia twice, I did my first LP on a kid, and I saw more central lines placed that I believe I could now do one on my own. I took care of a ventilated congenital cardiac kiddo---balancing lasix and fluids carefully. I took care of a very sad head bleed teenager---she was in the bed of the truck when it rolled over. I managed a very dehydrated kiddo (sodium=170!) and normalized her sodium carefully. All in all--I learned a ton but I also experienced awful things.

My second to last day we had 3 children die. It was probably one of the worst days of my medical school career. (I had a hanging death of a college student while on trauma which now is in second place) The first death occurred around 9am: it was a previously healthy 6 year old who had a T&A (tonsil and adenoid removal) the previous day. At 4am, mom gave him hydrocodone and by 8am he was blue and not breathing. We coded him for 90 minutes. And just before we were about to call it, someone found a pulse. So we put him on a epinephrine drip to allow mom & dad to say goodbye. It was so sad. By the time it was all settled it was around noon. I grabbed a quick lunch and then was told there was a 2 month old boy coming in coding. He was sleeping on the couch with dad and dad woke up and he wasn't breathing. We coded him for 60 minutes, but he did not make it. The final death was a cardiac kid who went to surgery. I came up from the ED after the 2 month old didn't make it to find out that the cardiac kid died while in surgery.

I pretty much cried all day. But it got me thinking which is "better"---having a sudden situation, where your child passed away suddenly and out of the blue, or having a chronically sick child and them passing away in a high risk situation---aka surgery---but a situation that you believe will save their life. I am not sure which one "wins."

Things I learned way before med school....

So I recently (aka Monday) started my rotation in the PICU -Pediatric Intensive Care Unit- and let me tell you---its intense! More on that later....

We had about a 10 minute break the other day and started looking up kids on the floor that might come up to to the unit. At one point the peds resident recognized a kiddo there and started telling me their story:
Its a 10 month old kiddo who has had chronic diarrhea since birth. They've done all kinds of tests to figure out the cause. They found out the kid is unable to digest both proteins AND sugars. This is actually quite rare. Apparently kiddos usually just have one problem or the other, but not both at the same time---this is a good thing because if you cannot digest proteins, then we give the kid sugars to eat, and if you cannot digest sugars, we give them proteins. For this kid they are playing a fine line in feeding him.

The lesson with this kid??

Don't marry your cousin.

Boo-ya!

Jokes made by Dr. S:

How do you hide medical information from an orthopod?
----publish it!


How do you hide patient information from an orthopod?
----put it in the chart!


Booya!

Bonding

This morning was clinic day with Dr. S. I was pretty excited about it because Dr. S told me that we would have at least one HIV positive kid, and not to sound morbid, but I was looking forward to it, because I find HIV fascinating and I've not met a known HIV kiddo before and I wanted to learn about how they were diagnosed and what their prognosis was like, etc.

18 year old R was our first patient. I walked into the room and there sat a healthy appearing cute kid. Cute enough that I would let my daughter date him. He was polite, and answered all my questions. He was diagnosed with HIV as a small child---it was passed on perinatally meaning while his mom was pregnant. He is currently on four medications to suppress his virus*---some of which he has to take twice or three times per day adding up to at least 9 pills per day. His viral load has been undetectable for several years. Meaning he is doing great. So great that Dr. S has wanted to change his meds so that he only needs to take 2 pills per day. But R has been reluctant to do so because he is doing so well and he is worried about going downhill once he changes his meds. Pretty amazing for an 18 year old. Most 18 year olds can't even remember to brush their teeth or put on deodorant.

When Dr. S walked into the room R jumped off the table and gave him the biggest hug. I didn't start crying (that would have been my usual reaction) but I felt this over whelming joy --- like Dr. S and R had this amazing bond and all I could do was to hope that some day I would have the same bond with my patients. After their inital hellos, R opened up and told Dr. S that he was smoking 6 cigarettes per day and pot about 2 times per week. I was impressed with his honesty but sad he was headed down that road. So Dr. S and I gave him a talking to, where I suggested running instead of getting high because it is a "natural high."

And alcohol and rock n' roll will send you to hell!! Sigh..... kids probably think I live in the 1950s.


* in talking with the mom and the kiddo---I realized they knew more about antivirals and HIV therapy than I probably ever will.

Data Collector

I've been working my butt off in Peds Infectious Disease. We cover two hospitals, plus there is clinic so basically we're constantly picking up new cases and finishing up others. We've got some sick kiddos recently: a Rocky Mountain Spotted Fever, lots of osteomyelitis, Leptospirosis, bacteremia sepsis, and today I diagnosed malaria!



But part of the hardest part of this rotation is getting my thoughts together in order to get the assessment and plan ready to present. I am good at getting the information--I can ask the important questions, and I can pick up abnormal findings on the physical exam. I can also get the vital signs and the lab values off the computer. After that I am supposed wrap it up with a simple one line sentence and explain my thought process for what I think it is. This is where I falter. While I was on ED I could get it together, but on Peds ID, I am usually so confused and have a billion things running in my mind that it sounds like blllllaaahhh.



Lucky, my attending sort of expects this. He believes our teaching was geared at making us great Data Collectors and looking back over 3rd year I actually completely agree. For example, on surgery I would wake up early to "round" which really just means I would make sure to find out if anything bad happened to my patient while I slept. If that was a no---did they eat? did they have a temperature? did they get out of bed? how was the pain? after I collected that info and their vitals and labs (which we rarely ordered anyway) I would just recommend that they eat, get out of bed and make sure their pain was controlled. Done and done. On OB it very similar only I'd mention something if they wanted any form of birth control. On psych I never rounded. On medicine we were told by the ED what they had, and we just consulted various services so I'd make recommendations on that and I'd look up journal articles to learn.

So it seems like I really didn't have any creative thought of my own when it came to summing up the patients---I was medical student, the Data Collector.

off it went

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I submitted my application for residency last night (AGHHH!!) and I am freaking out (AGHHH!!). I tried drinking a beer after submitting, but in all honesty---it didn't help. So I might go towards heavy drugs---like chocolate.....

I wasn't going to submit until next week (I'm still waiting for a couple of letters of rec) but after talking to the Peds Residency Director---it changed my whole outlook. It was a simple run in---we both happened to grab our lunch at the same time. He is super friendly so he asked me how I was doing and what rotation I'm on, etc etc. Just plesant chat until we hit the elevator. Thats when he asked if I submitted yet. I said, I was working up the courage. Thats when he mentioned that he already had 250 applicants. 250!!! The option to apply was only open for 30 hours at that point and he already had 250?!!?! So I went home and stared at my computer until I finally hit enter. And off it went.

So I've checked my email about 30 times today in hopes to have an interview request. But no such luck. The worst part is you can look up who has downloaded your application. Several have downloaded it. Still no interview requests. AGHHHHH

Having a kid is just like owning a pet.....

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My first patient on Peds Infectious Disease (Peds ID) was supposed to be a kiddo who lives in the near-by bigger city. I find it absolutely amazing that the neighboring city which has about 4 million more people does not have a single Peds ID doc. Instead they have to come here or the docs from my city, go up there. Well aparently this kid doesn't even have a doc to begin with---he's been seeing a veterinarian.

He got diagnosed with MRSA---the strongest bug there is out there! Its a resistant strain of staphylococcus (a bacteria) which will definitely need some big gun antibiotics. But instead of going to a doc for this diagnosis, his family took him to a vet. Aparently, it only costs $17 per day for the kid to stay at the barn shelter. Which I guess compaired to hospital bills ---this is a fabulous deal. Why did he go to a vet in the first place? no idea. What kind of MRSA does he have? no idea. Why do I not have the vital information on this kid? Because he was a no show in clinic today.