Since the beginning of August I've been working on my pediatrics rotation. It started mundanely enough with 8 am - 5 pm clinic hours, and by the beginning of September picked up in worktime, with 6 am - 5 pm the norm for a day's work, Monday through Saturday. Still, despite peaking with 75 - 80 hours each week not including time spent studying, pediatrics is the most enjoyable thing I have encountered in medicine thus far, and the largest reason for that is the children.
Early on in the first week of the rotation Dr. Groshong, the head of the pediatrics department, spoke to us about what he wanted us to get out of the next two months. He said the primary goal is for us to enjoy learning to care for children and have fun doing the work we do at the same time. That I enjoyed working in pediatrics is an understatement; there was no house officer or attending physician who was ever unpleasant to be around or ever was in so poor a mood it was intolerable.
Clinic duties consisted of me seeing a patient first, followed by a senior resident. It was through this process that I honed my skills in interviewing and examing patients. It was also through this process that I learned how fun it is to engage children. One very memorable moment was when a 6 year old girl with a rash hopped off the exam table, pulled up her shirt to show off her belly and yelled "Wanna see it?!" Children are so excited to have an adult's attention, and I was perpetually eager to dispense as much attention that was needed to make the visit pleasant for the kid.
A few times in clinic there were patients that elicited fear of serious concern from me as a budding clinician. The time I was most concerned was when I approached the exam room to see a 2 month old boy and read the nurses note on the chart stating "coughing up blood" as the reason for visiting. My first concern was whether it truly was blood, or something less serious, and I truly hoped in my mind it was a mistake. The family was young; the mother only 17 at best and a father who was of similar age, living with the mom's grandparents. The father described that the child had started to cough, began to be frothy at the mouth, and when he wiped away the spit noted that it was tinged with blood about an hour earlier. Later during my exam, with the baby on his back on the table, he began to cough and gurgle again. I grabbed a few paper towels and stopped my exam and just waited. I waited long enough until I noticed pinkish frothy sputum at the child's mouth, and wiped a large portion away only to see it was thick with blood. I set it aside as my evidence for true hemoptysis (coughing up blood) and began meticulously inspecting the inside of the child's nose and mouth for a source of the bleed other than the lungs. There was no discernable source, and a more ominous sign was the sound of wet crackles coming from the child's lungs through my stethescope. A chest x-ray performed in the clinic showed a diffuse clouding of the lower right lung, and the 2 month old was rapidly admitted and treated with antibiotics for a possible unknown infection. Other concerns were a possible tumor or foreign object in the lung.
I finished my outpatient weeks at the Green Meadows General Pediatrics clinic and moved on to inpatient pediatrics service. It was an adjustment to have to start the day before sunrise, but the plus side was there was little to any traffic to deal with on the drive to the hospital. The atmosphere of the ward was one of running an efficient machine; a day consisted of a systematic hand-off of information on patients from the night float physicians to the day team, a pre-rounding and data calculating period, determining the quantity of fluid and caloric intake versus fluid output a patient had, the days and dose of antibiotics or medications, lab results as well as those pending, attending rounds with the head physician where the treatment plan was discussed and adjusted, afternoon "power hours" where all the work needed was done for the day and progress notes were recorded. Phone calls would be made to receive lab results or schedule consults or follow up appointments, follow up visits with the patients would be performed, reporting to the intern or resident about changes in patients occurred, and new patients would be admitted by the intern and student on call that day. At the end of the regular work day the night float team would arrive, and the info on patients would be relayed systematically to the physicians and hand-off would once again occur. Patient management was, in short, a careful process of adjusting the vital signs and symptoms of a patient to a point of better health, be it by symptom control until the illness passed or disease process control to provide better baseline health.
Despite the many similarities to auto mechanics inpatient medicine had in my head, it was not without attention to the psychosocial aspects of the care of the patient. One patient who taught me a great deal about the importance of caring for non-medical needs was my little refuge from Gabon, Africa, who I will call Edward (not his real name, though). Edward was a 9 year old boy who came to the US with his family as refugees and spoke only French. I admitted Edward on a Tuesday evening in the ER, at the end of what had been a rather blue day as I ruminated over several things that had been on my mind as of late. For the past 4 days his knees and ankles had begun to swell and become painful, and a day after arriving in the US was so painful and weak he could not support his own weight. He was accompanied in the ER by his father and the refuge service case worker of the Jefferson City Diocese.
Edward was scared, quiet, and in obvious pain and discomfort. He was a very slender 9 year old child with little muscle mass, and although not emaciated, did not have much cutaneous fat. He and his father had arrived in the US the day before and had not slept since the previous morning. They were exhausted and earnestly desired to go home, however the father wanted to do whatever the doctors deemed necessary for the child's health. A tap of the left knee joint to draw off fluid showed a large amount of white blood cells and a lot of inflammation. It was also learned that the boy was HIV positive, and being highly concerned about the possibility of joint infection that could devastate the child's knees, we admitted him to begin treatment that would last 18 days. In those 18 days Edward and I would develop a patient-physician connection that demonstrated love and hope in a way that surpassed the language and cultural barriers present between us.
To be continued...
