Thursday, November 04, 2010

Peds, week one

Neuro redux coming soon...lots to say on that one, but let's just say it is off the list of possible career choices!

I started pediatrics on Monday...really Tuesday, since Monday was just orientation. My medical school class gets divided into three health systems for each clerkship, and then each of the health systems subdivides into main campus, community hospitals, etc. I am the only student in my health system that is at a community hospital--it is a new program, and there is only room for one student at a time. It's been a much different experience from what I have heard about people doing pediatrics at one of the main hospitals.

First, it is a hospitalist service. There is a practice of pediatric hospitalists who only see inpatient kids. They also cover newborn babies. Basically, community pediatricians have the option of managing their patients when they get admitted (or are born), or they can choose to have the hospitalist service manage their patients. That means that, currently, there are three patients being covered by my service on the peds floor, and there are 15-20 babies/day that need to be seen either for admission (after birth) or before discharge.

The pediatricians can also be called to deliveries if the OB has a concern that there might be trouble with the baby. I got to see my first delivery today (that wasn't for my own child)--the concern was for an IUGR baby, but she turned out just fine. I did get teary watching the baby being born--it's such an unreal event! I still have no interest in OB/Gyn though :) That's next month...stay tuned...

On this service, we get signout from the overnight physician on call from 8-8:30. The resident and I then head to the peds floor and see whoever is on our service. The attending is usually in the nursery seeing the newborns at that time. Then the attending comes to the peds floor, we go over the patients, and we are usually done around noon. Then it's lunch, and so far this week, then it is dead time (though this would be the time for admissions if they come in). It's good in some ways: after crazy neuro, it rocks being able to eat and pee during the day, it gives me time to look up med information, and we've also gotten to do some teaching/learning about important peds topics (jaundice and asthma so far).  The down side is that it is SLOW, and I am worried I may not get to see everything I need to see.

For instance, we had the ER call the other day with a kid who was vomiting. However, the kid was a newly diagnosed diabetic. This peds unit doesn't take diabetic kids (unless the community physician is willing to come in and manage them, which they generally are not) because they can be so sick so quickly. So this kid got sent to main campus. We had another call yesterday for a dental abscess, but there is no dental/oral surgery here, so he got sent to another hospital. Basically, we get jaundice, asthma, acute infection (pneumonia, GI, etc), MRSA abscesses, etc. That's not quite what I was hoping to see. It does make it feel manageable--anything touchy never really gets to us--but it's not what my peers are seeing in some of the tertiary care units in the big-name hospitals.

I did see one case yesterday that I wish I hadn't. Again, no details due to HIPAA, but we had a child come in that had evidence of (and self reported) child abuse. This child had "only" belt welt marks on the leg, but there was a history of abuse by the older sibling that required stitches and a general history of hitting/verbal/emotional abuse by both parents. The child was very pleasant and social--a bit energetic, but nothing off the charts for the age. Talking to this patient was tough--the patient talked about how the parents didn't want them anymore, that the parents gave them medication (focalin and risperidone) "because I am crazy," how the older sibling threatened to kill them at night, etc. The parents were arrested and put in jail briefly after bringing the patient to the ER (initially for "behavior problems"), and reading the note was so sad. Apparently, no one was willing to take the patient--the grandparents agreed to take the older sibling, but no one wanted the patient.

We of course got social work and the county involved, but the county wouldn't take the patient. So, despite a restraining order, the parents got to choose who took the patient. There was much drama last night while I was on call about who was actually coming to pick the patient up (and whether one of the people was actually the mother posing as someone else). We did all we could to try and get county/temporary foster care to take the patient, but they wouldn't. When the person picking up the patient arrived (with security, of course), it was obvious that this person was annoyed and wanted nothing to do with the patient. We all stood helplessly at the nurse's station as the patient left, knowing that more than likely, the mom/dad was waiting in a parking lot nearby, and the person who picked up the patient was going to ignore the restraining order and give the patient to the parents.

We all had fears that this patient would get beaten, and the parents wouldn't come back to the ER, since they got arrested last time. This patient was returning to a terrible home life. We protested, we called social work/the county continuously all day long, and there was nothing we could do to keep the patient from it. I'm praying that I don't recognize any news stories in the next few days. The attendings were frustrated too, and they had other stories about abuse kids--how long it took to finally get kids removed from homes, how sometimes what you fear ends up happening, and just generally about how some parents can do such terrible things to their kids. The attendings tried to reassure me that cases of abuse like this are rare, but it didn't make me feel better about this patient.

I am a fixer, and if I could have, I would've personally taken this patient away from the family. I wanted to protect them from what they were facing.  It was so sad--the patient said that they feared the mom, dad, and sibling, yet they wanted to go home. While the patient was here, all they wanted was approval. They tried to please the nurses and doctors. The patient was happy and social here--I know no one can live at the hospital, but the fact that life in a little room was better than what waited at home was so sad. The entire time the patient was in, no one called about them, no one came to visit, and no one wanted to take them out of the hospital. It was absolutely heartbreaking.

It also exemplified the biggest concern I have about peds. Let's start with what I like first: the people are great, I enjoy working with kids, and so far, the hours are fantastic. The downside: depersonalization (or lack thereof). I am so protective of these kids. The first day, there was a patient the exact age of my son. The patient's parents were teenagers, and they really wanted nothing to do with the kid. The child couldn't roll over, couldn't sit up, and actually had a flat head because of always being laid down. The parents were never holding the baby when we came in--they were sleeping at all hours of the day, and the patient was in the crib, alone, all day. The patient was so excited to see other people come in! I wanted to smack the parents around. If you don't want the kid, give them to someone who does!

Other patients have been fine--there are plenty of parents who are very worried about their kids and want them to get better. But I think I would have a hard time in peds dealing with parents who obviously could care less about the kids--or worse, parents who are negligent/abusive. I am way too involved with that emotionally. I don't expect parents to be perfect--I am FAR from perfect, and I think a good chunk of parenting involves making mistakes. However, if you learn from the mistakes, and you try to be a better parent, that's the right thing to do. I just don't know if I can see parents that are uninterested or mean to their kids.

The attendings have said that you get desensitized to the parents, but I am not sure if that is good or bad. I think children need advocates. I'm naive in the sense that I think I can make a difference. I don't think I can fix every bad parent out there, but I want to help the kids that I do come into contact with. I just don't know if I can do peds.

And, if I did peds, I couldn't do general pediatrics. I know nothing as a med student, and already some of general peds is mind-numbing. It's the same issue I have with adult medicine--my personality is such that I like knowing a lot about one small specialty, and I like when things are challenging. It's a balance though--I don't want every case I see to be life or death, but I want to have to think about diagnosis/treatment challenges regularly. I like being a detective. Specialty pediatrics could be a lot like specialty adult medicine, which could be fun. But I'd still have to deal with the parents. At least adults are responsible for their own bad decisions. Kids don't have responsibility for what their parents do.

I'm curious to see how I feel at the end of this month. Maybe I will learn to depersonalize and find a way to channel my need to smack parents upside the head. I really enjoy the medical people so far, and they seem very understanding of work/life balance. Those are definite advantages. However, I don't want to come home and feel demoralized and dejected because I couldn't help kids the way they needed to be helped because their parents got in the way. 

I may have to do a rotation in one of the busier tertiary care pediatrics wards to see what that is like. Other med students have said that their pediatric rotations were intense and very busy. While I am thrilled that this is low key (I need a little of that in my life right now), it may also not be representative of real life.

Plus, there's always the issue of what to do with my PhD if I do peds. I'm still not convinced that I want to do bench research again, but I also don't want that six years of my life to be a total waste, career-wise.

I guess this pediatrics thing is still TBD. I like the medical people, I like the lifestyle, and I like kids. We'll see if that is enough to put pediatrics on the list!

1 comment:

  1. I went to school for 30 years. I have never been sorry to know something. Look at your sidebar regarding your PhD "bosses" and consider how hard it is to successfully run a lab. It's not about the bench work its about the funding.

    As far as Peds rotations, just do a month of pediatric ICU rotation later on at the one of the Ivory Towers. You will have all the intensity and high tech medicine you can stand, you will see truly sick kids and you will see truly sick kids recover AND you will have a dedicated ICU experience. Since you already had this community experience you will be long past how do diagnose the flu and you will easily be able to concentrate on a meatier agenda.