Thursday, December 23, 2010

Peds recap

Late, as usual, but here is a quick recap of my one month pediatric rotation (done in November). I'm a little behind partly because I have been crazy busy, but I've also been trying to think about what to say that might be helpful when 4th year "me" is debating about residency applications.

Peds (pronounced PEEDS in the biz) started out not so great, as I noted in an earlier post. It did get better, though as I will mention in a minute, many of the undertones of concern from that first week lingered throughout the rotation. Overall, it was pretty benign--any of the really sick kids get sent from the hospital I was at to main campus. Basically, my team's job was to recognize when kids were really sick and needed to be sent out ASAP (there were a few of these), when we could treat them in-house, and when they could go home. Part of the issue was that outside pediatricians could admit their own patients, but as the house team, we did their admission history and physical (H&P). There were many times where we checked the patient out and really didn't think they needed to be admitted, but the outside pediatrician was in charge of their care, so we went along with it.

Most of the kids fell into: bili babies (high bilirubin in newborn babies--they just spent some time under phototherapy lights), gastroenteritis, RSV/bronchiolitis, asthma, or MRSA cellulitis. There were a few other kids that didn't fit into this category, but I'd say 90% of the kids were one of the above. There was one case that was pretty tough emotionally (in addition to the one I talked about before): we had a 5 week old boy come in for failure to thrive, and he ended up having pyloric stenosis. He got his pyloromyotomy, stayed in the hospital a few days, gained some weight, and went home. There were concerns in the hospital about the mom--she wasn't all there, and she visited for about 15 minutes a day while the baby was in the hospital. There were no outward signs of abuse, and social work checked her out, so the baby went home on a Sunday.

On Tuesday, the baby was back in--he had lost significant weight even in the two days since he went home. When he was admitted, mom was told she needed to stay with him 24/7 and do all of his feedings so that she could be observed. She had been given a rigid, every 2 hour feeding schedule, and it came out the first night he was in that she hadn't been waking him at night (or if he was sleeping during the day) to feed him. There was a lot of drama with her, and the baby was still vomiting most feeds/not gaining weight, so it was a tense few days. Two or three days into the baby's admission, the mom admitted that the baby was too much for her (she had a 4 year old at home too), and she was willing to give the baby up for adoption. It came out that she didn't even know she was pregnant until her third trimester, the baby's father was a short term relationship, she hadn't told him about the baby, and he had cerebral palsy and would be unable to care for the baby even if he had known.

It was an obvious relief to her when she heard that she could give the baby to a family who could love and care for him. It turned out that an extended family member (along the lines of a second cousin) wanted the baby, and adoption proceedings started the next day. As soon as the mom said the word "adoption," she left the hospital shortly thereafter (visibly relieved), and the baby was put into temporary care with the future adoptive family (the mom gave them temporary guardianship) while social work figured out the details.

It had to be tough, but at the end, it really worked out for the best for the mom and baby. I wish them both the best.

So, there's a mostly happy ending. Overall, most parents came in, obviously concerned about their kids, and they were cooperative and pleasant to work with. I loved working with the kids--they were sick enough to be in the hospital, but they weren't chronically sick, so they felt better pretty quickly and were social/playful while on the ward.  I am sure it is much different with chronically sick kids.

The likes:

-The attendings. Personality-wise, I am probably a perfect fit for peds. All of the attendings were awesome--great teachers, interested in the kids, social and helpful with the team/each other, and they all had lives outside of the hospital. I had a lot in common with them, so there was always a lot to talk about on call/during downtime. I missed them as soon as I started OB!

-The kids. I just like kids. This was a good group of patients, because we helped them from being really sick to being nearly 100% recovered within a short hospital stay. Again, this is totally different from chronically ill kids.

-The lifestyle. This group is a hospitalist group, so they rotate weeks on service and overnight call. Many of them are hospitalists at several local hospitals. Your service week is 8-5, and call is 5PM-8AM (with 24 hr weekend call). It works out to a week of service every 5-6 weeks and call a few times a month when you are not on service. It's great.

-I'm not going to put salary as a plus or minus. It's not as much as adult, but once again, anything is a step up from where I am now.

The potential dislikes:

-The parents. This is a potential dislike, because there were only two cases in the month I was there that parents were a big issue. Most were compliant and pleasant. However, I can see how, long-term, parents could be a stress. If they aren't interested in helping their kid get better, that would infuriate me. I'm an overprotective person, and it wouldn't be very professional to go all mama-bear on them.

-The routine. The way I see it,there are a couple of types of pediatrician lifestyles. There is outpatient, which really doesn't interest me (though I have yet to do this part of my rotation). That is full of well-child checks, colds/flus/strep/ear infections, and other non-intellectually-stimulating activities. There is always the chance you will see a really sick kid who needs to be admitted ASAP, and a pediatrician needs to remain vigilant for that reason. The other end of the spectrum is something like peds heme/onc, where you deal with chronically sick kids (cancer patients, in this case). From what I've been told by attendings, kids that have to stay inpatient for their cancer usually die, and I think working with dying kids would be exceedingly tough. My attendings said that most kids can get their treatment on an outpatient basis (after an initial inpatient admission), and those are the kids that can do ok. My one attending said that every kid she followed during her inpatient heme/onc time died within six months of her seeing them. I don't think I could handle that. The general inpatient I was on this month would be ok, but even I had the protocol for the usual diseases memorized in a month. I don't know if I could do that long term--I might be bored to tears.

The happy medium is probably a pediatric specialty. We had a few cases at the very end that involved a pediatric cardiologist, and that could be a good overlap between my cardiac research and peds. I'd need to do an elective to see what it is really like, but it's a possibility.

-The unknown. I really like kids, but I don't know how it would be to have my own kids and see other people's sick kids all day. Would it make me a hypochondriac about my kids? Would it burn me out? I don't know.

So, the overall is: maybe. I'm curious to see how I like medicine. I think peds stays on the list, unless I find out that I absolutely love something else. If it does stay on the list, I need some more exposure, both more serious illness (like a peds ICU, which someone suggested) and some specialty exposure. I am just worried that I may not have enough time in 4th year to sort all of this out.

I have one more week of OB/Gyn after the holidays, and then I can give that recap. Overall, I have to say that I am very unimpressed so far (to put it mildly).

Thursday, December 16, 2010

Nearing a break

I am so over OB/Gyn--I have one more week of it left after the holidays, but starting tomorrow afternoon, I get two weeks off for Christmas! This time will be filled by a huge catch-up list, which includes some blog time. I need to catch up on sleep first--I averaged 4-5 hours a night before going back to third year, 1-2 hours/night while I was writing my thesis/doing 3rd year (and several sleepless stretches of 2-3 days at a time), and I'm up to 3-4 hours per night right now. I'm functional, but I'm not fun. There is some serious sleep debt to fill (I know you can't actually make up a sleep debt/bank sleep, but it isn't going to keep me from trying!)

I just have to get through tomorrow, and then I only have my giant to-do list left!