"How are you able to continue working after witnessing a death like that?"

I had a great question from a very insightful medical student after the first case of our day was to Code Blue that did not get any better. The code was on a young patient in my primary care. She was very unwell, and I'm sure nothing would that have changed the outcome. Tragic, true, circle of life type stuff. 

Initially, I felt really upset with myself. How could I just move on? I know this woman and her family quite well. Should not I be more upset with what just happened?

With every death, every code, I ask my team to do a quick debrief with me (longer if needed) to ensure that we did all that we could, and needed to do. I go over everything in my head as well. Where could I improve next time? Were we all wearing PPE? Did I speak with the family in a respectful, clear manner ?

This time around, the police were with us. We're a small town, so all tragedies involve them. It's great, because they call victim services if needed, get in contact with distant relatives, chase after teens who "can not take it" and run off. They are a really good bunch. They surrounded me and checked in on how I was doing. Asking if I would talk to someone if things went poorly. I am telling me I was a rock star in the trauma bay, That the family completely trusted me and was incredibly relieved to know that I would be the one working on their loved one. Basically making sure I do not get PTSD from the event - something I try to do for them all the time but was not used to having it in return. 

I was a bit upset, but felt like I was not upset enough. That I was a big faker pretending to care. 

It was not until yesterday that I was able to figure out why it is that I can just pick up and go on. This was the third patient that description fit that died in front of me this year that I was able to continue working after their pronouncement. 

I have a therapist. Everyone should. She helps me figure out things like this that niggle in the back of my head but that I do not take the time to work through. She helps me figure out when the culture of medicine is nutso and I'm right to ignore the culture and do what is right. 

Here is the answer, finally, med student of mine. I have an incredible resilience built around patient deaths. 

When I first got into med school, I knew that someone like me with a soft hear t might have a hard time with death so I sought out situations where I would be challenged. I thought about each deat h as an unavoidable event and looked for the way that I could make it the MOST comfortable for the patient and their family and (even when the patient is a baby). I learned that I could cry with family in a respectful manner. 

Each of those links is a blog post I've done during my training and practice to reflect on death and my part in it. I see myself as separate from the patient and their family. I love them in a way that is not family or friend, but caregiver. My role in their life is just a step in their journey through this world. They hold the same role in mine. While our lives intersect, my goal is to make our lives both better for the experience. I learn my lesson, then a go to intersect with another life. The lessons I've learned stay with me forever, but they are not necessarily emotional. 

Sometimes they are. A patient died of malnutrition at a young age, and you bet your ass I got angry and looked to make change. But, because I want the rest of my patients to be healthy, because i was not dwelling on his passing. 

So, my thought process goes like this; reflect on the death changeable and my role in it, reflect on the interaction with family and colleagues, move on to the next patient who needs to see me. This might happen many times during the day following that death. I still wonder if I could have done more for my patient before she died, but that use as a way to be a better doctor, not to dwell on the past. 

Death is part of life. My job is to keep moving forward. I see my getting back to work and helping other people as a way of respecting my patients' lessons to me. 

Eeyore

I convinced a 5 year old girl this week that Eeyore isn't sad, he's dysthymic. Hearing a wee girl without front teeth say "dysthymic" is awesome.


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My new definition of gross

Parents who kiss their freshly born baby after they've marinated in meconium full amniotic fluid.
Yes we wipe the kids off first, but still....Ew.




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Guess which room the jaundiced baby is in

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See one...

Usually in medicine, especially in the ED, you hear "see one, do one, teach one". This refers to seeing a procedure or technique done, doing it yourself then teaching someone else how.

In paediatrics however, it appears to be see one, see one, see one, see one, see one.....



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The most terrifying words I've ever heard

"Dr. Imposter we need you in the special care nursery STAT. RUN!"

I ran. And was terrified. I haven't learned paediatric resuscitation yet. Terrified.

Once I got there I was pretty much furniture. The RT and the nurses ran everything and made the baby go from yucky looking to feisty. These guys rock.

Once I could feel my feet again I asked the RT a million questions about what had happened, and I learned.

I also learned that I was not as calm in the face of a critically ill patient as I thought I'd be. That was eye opening.

I need more practice in dealing with scary situations. It's difficult to convince patients to let me make them critically ill so I can learn. (jokes)


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Princess Peach

Kids love iPhones. They play games on them, watch YouTube, and take great photos.

Many of my patients play Super Mario. They have Wii machines in the hospital for them to use. I'll make these kids puppets from tongue depressors with Mario, Luigi, and Princess Peach. It's a cheap distraction that lets me examine bellies without voluntary guarding from the patient.

One of the patients had an iPhone with Super Mario on it. Watching him I was shocked at how quickly he was moving through the level. And ashamed of how poor I am at playing the game compared to a 4 year old.

Then his mom told me he was watching videos on YouTube of someone else playing the game.

D'oh.


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Nursery wackiness.

Why is it that once one baby in the nursery starts crying, they all start crying?

We were desperate for a soother. Couldn't find them. Disaster.


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Irony?

Getting sick on my paediatric rotation because my preceptor keeps coughing in my face.

In other news, I've avoided all wee ones coughing in my face so far.

Gah.

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Quilt in progress

It's strippy.


Today was my first day on paediatrics, so I feel overwhelmed and stupid. That seems to be the purpose of every first day on rotation.

To gain a tiny bit of control, I am sewing together hundreds of strips of pretty fabric.

Kitty approves.



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Sick day

I look forward to the day when my immune system is able to fight off the flu all those cute kiddos keep coughing in my face.

At least kitty keeps me company.




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The word that will make every 3 year old boy laugh

Even if he's so sick he can barely hold his head up....

Bum. There's just something hilarious about a doctor saying bum.


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Chief Complaint: abdo pain

Final diagnosis: PTSD

More than just once in a while I'd like the cute little kids who come into the ED to just have a cough.


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Kids say the darndest things

I have an adorable young family who comes into the office. Every time I see them I giggle because mom allows the kids to dress themselves. Sometimes I'm treating princesses other times race car drivers. They are a lot of fun.

Yesterday, Kiddo was in for a sore ear. Every time I tried to look, he'd swivel his head around to look at my stethoscope. Finally I just hung it around his neck so I could do the exam.

While I was telling Mom what I saw, Kiddo put the bell in the middle of my chest and said "ba bum ba bum ba bum". I asked him what noise my stomach made. He said "whooshy wishy woosh". I asked what noise his knee made. He said "sqeeeeeee". Then I went back to th exam but he clearly wasn't done. He said "what sound does you boob make?" put the bell on my breast and said, "woooo-uuu, woooo-uuu".

Mom quickly stuck out her elbow and asked what sound it made.

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When there’s nothing left to do

A young patient showed up in our paediatric ICU from a periphery hospital. We were told that she had diarrhea and fever that was refractory to treatment, but the x-ray images which were supposed to accompany the patient were lost. Usually this was a hindrance to care but in this case, it meant that we were able to discover what was happening much sooner.

Looking at the abdo x-rays with fresh eyes, we realised that our patient likely had lymphoma which was causing the lymphatics in her abdomen to become so enlarged it was impeding her ability to pass stool, causing overflow diarrhea. Her decreased appetite noted in her transfer file was caused by an obstruction, not as a side effect of the suspected infection. A biopsy confirmed our suspicions and also let us know that this was not going to be curable. It was horrible.

Our patient was an adorable young girl, curly hair, puffy face, fever for months and clearly unwell. She played in her hospital crib while she could, but mostly she slept.

These conversations are never easy to have with patient’s families. They are especially hard to have when the family knew that their child was feeling unwell and the news they were about to receive was horrible.

My consultant took the patient’s family into the quiet room every ICU has. The parents did not want to leave their daughter alone but I was happy to miss this particular conversation. I stayed with the little girl, playing in her crib, then holding her in my lap and rocking her while we watched Dora. She eventually fell asleep there, I am known for being soothing and tend to make children fall asleep quickly. I’m proud of this super power.

When the family came back. obviously distraught, they stood around their daughter and I. These poor folks were so much in shock from the news that they had just received that they didn’t know what to do next. I ended up gently standing up and asking her father to sit down and take her, which he did, sobbing.

My consultant thanked me for caring for the patient, said that it seemed to comfort the parents while they were in their meeting. She really wanted me to go into paediatrics because I’m able to insert myself quietly where I’m needed and so few med students/docs seem to do this well. To me, it just makes sense to snuggle a sick child when she needs it, to hug a family who has just lost their husband, to cry with the woman diagnosed with breast cancer metastasis and to joke with the families under so much stress they don’t know what else to do. I try to do it in a way that isn’t “too familiar” but makes the patients and family feel cared for. I step out again as soon as I can.

When I got home the night after my snuggle, and expected to be more upset than I was. I felt good with the choices I made that day and how we had been able to do what we could.

With the sick kiddos I met in the ICU, I decided to squish as much love and care into their teeny bodies as I could in the time I had with them. If I’m able to maintain this outlook, I really think that I may be comfortable with paediatric palliative care.

"Things will get easier, people's minds will change, and you should be alive to see it"

I know it's cliche, but our media is not doing teenagers any favours.

Ellen's talk about the teen suicides in the US that are following bullying is powerful and long overdue. Not just by her, but by adults and media in general. Everywhere they look, media is focused on teens and telling them what to do, how to look and who they are expected to be. Bullying isn't just taking place by other kids targeting children kids who are different, who may or may not be gay.

Idiots on the net are suggesting that the kids who are killing themselves to escape the bullies were mentally unstable before the bullying began, that being gay is a form of mental illness. They clearly forget how hard it is to be a teenager. It's incredibly difficult to keep your wits about you while figuring out who you are and dealing with surges of hormones. There are few teens who are mentally stable to begin with. Add bullying to the mix and it's surprising there are more episodes of suicide than there already are.

I was one of those kids who was teased about being gay before I had discovered for myself that I wasn't. To me though, this teasing meant nothing because I didn't see anything wrong with being gay, as long as they didn't call me fat or stinky I was OK.

Again, movies, TV and magazines tell us that if we do things perfectly -by wearing the right makeup, dressing in tight clothes, sleeping with whoever we please, drinking alcohol and still being brilliant at school, friendly, athletic and thin - we will have more friends than we know what to do with.

No pressure.

Hard to imagine why kids struggling to define themselves are struggling so much. Each teen is fighting this battle and has a difficult time recognizing that they have peers fighting similar battles. It results in them feeling isolated and ignored and trying to find a way to be seen. They become bulimic, goth or emo; buy crates of makeup and perfume; dress like sluts; slowly self destruct.

I've spent a few weeks with the child psychiatry team and these messages and how teens deal with them have been at the forefront of my mind. There isn't a fast solution to the problem which seems to be systemic. All I can hope for is a change in the content of the messages being broadcast to our youth.

Imagine you're a ten year old kid. Your thinking is still very concrete; sarcasm and shades of grey are completely lost on you. If someone tells you that you are too chubby you believe it. If someone tells you there's an obesity epidemic - that being fat is unhealthy - you believe that too. Then you start to pay attention to other messages from media, school, peers and adults. Foods low in calories, low in fat and sodium are healthier choices. Empty calories that you get from foods like the pop and chips you enjoy occasionally with your family are not good. Rules for eating and exercising begin to be formed in your head, all because you want to be more healthy.

Congratulations, you now have an eating disorder. Not because you think that you are too fat and need to look better, but that you are unhealthy and want to become healthier. Without countering the restrictive messages with messages of balance, enjoyment and the importance of certain nutrients like fat, this ten year old can become an eleven year old who is so malnourished, has a heart that is so wasted of muscle its SA node no longer function and an EKG tracing shows a junctional rhythm. The only option is to put this child into the hospital, provide him with nutrients at a rate that will not cause refeeding syndrome, and teach him the way to feed himself in the future - a balanced approach to be healthy.

Adults and especially health care professionals have a responsibility to keep the messages kids receive safe. Ellen is right. This is a crisis.

Losing track of the big picture

Something that happens quite frequently, especially in pediatrics is a lack of acknowledgement of the child as a person. This unfortunately also becomes a lack of acknowledgement of the parent as a person.

As a team of consultant, senior and junior residents and medical students, a herd of eye balls moves room to room in the hospital. The herd parks outside the patient's room and talks about the most recent blood work, biopsy results or imaging. They engage in an intellectual discussion about the findings and what they will mean to the patient's prognosis or treatment plan. They enter, usually without knocking and
discuss the plan for the day. Hopefully, this discussion includes the patient and family.

Families are often starved for a sense of being a part of what is happening. They can feel like animals at the zoo. They deserve better.

Medical students often feel like we are bothering the family when we want to ask more questions. There are lots of things that these families can teach us and allowing them to be medical teachers in a teaching hospital allows them to feel less out of control of the situation they are in.

Obviously not every family feels this way. The easiest way to find out is to say something like "hi, I'm the impostor, would you mind if I learn bit more about your child, her illness and what's been going on for your family?". If they have had enough, they will either say no or answer in short terse phrases. Thank them and wish them well.

If however they start to glow and want to tell you everything about the presenting signs of illness and the path taken to get them to your hospital, listen, ask questions and enjoy the experience. I've learned so much from parents.

By the time the child is worked up and on the floor, the reason their parents first brought them in can be lost in the shuffle. Leukemia can first present as sore feet. Cardiac arrhthmias may act like nausea and vomiting.

I've also learned that kids hate a 'pity party'. They want you to ask what sports they play, what video games they have, compliment them on their pajamas. They hate it when we come in, head tilted to the side and with a gentle sigh ask how they are feeling. Treat these kids, especially the cancer kids, like regular kids. They'll tell you if they need something else.

Final lesson, introduce yourself. Telling people your name seems only fair when you know everything about their child. It lets them know you see them as a person rather than just a file.

And frankly, not doing so is just plain rude.

ICU, kind of awesome

Stupid Shozu isn't working again so all my posts from this week haven't shown up.

I've been in the peds icu for my selective. I was really surprised by how few kids have actually been so acutely sick they needed the one on one nursing. It's mostly been a holding pen for the peds floors upstairs.

When acuity does happen, it's exciting. Everyone has their job which they perform well. I was told last week that it wouldn't have mattered if I'd forgotten to pass on that a blood sugar needed to be monitored because "this place runs itself". It's kind of true.

There are many protocols in place to give nurses guidance when orders haven't been written yet. The nurses pretty much run the joint. And
love their job. They have been teaching me all kinds of great stuff like physical findings on kids with congenital disease and why certain feeding protocols are in place.

We start our days by doing handover from the night before, this is done around a table with residents, consultant, nurses and RTs there. Then the residents and I pre-round on our patients. I always get the very well patients so I'm usually done quickly. Then we do xray rounds, looking at the most recent chest films before we round on the patients and potentially change their orders for the day.

Then it's lunch.

The afternoon is spent doing physicals on our patients and writing complete notes and doing teaching if we have a great (read learner
friendly) consultant.

I love ICU, but I think I need more doing and less talking in my days.

looking forward to the weekend

I'm due for some relaxing and kitty snuggling. While I'm loving paediatrics, I really need a little break.

mmmmm, tastes like summer

after 4 weeks of paediatrics I'm ecstatic to have the weekend off. Not just off, but spending it outside listening to live music and enjoying the weather. And becoming mildly intoxicated.

In the paeds ED, in no paticular order I:
sutured 3 fingers, a lip, a head
saw kid vs. lawnmower
saw what emotional shock can do to the parent of kid vs. lawnmower
fish hook in finger
first presentation of brain cancer
set 2 feet and 2 arms
way too many kids with constipation, gastritis or a cold
one over worked mom who just needed a bit of quiet time and reassurance
several cases of cocksackie
possible child abuse vs. anorexia ?vs. crohn's (that's something for inpatient to sort out)
a kid with a cold whose dad was worried the dying mother might get sick if they visited and wanted permission to go see Mom (heart breaking, especially when they were triaged as not important)
well,sick, happy and sad kids

it's been a good two weeks