The Medical Apprentice

It was an epic battle.  Weighing-in at 23 pounds and wearing a pink puppy-dog shirt, she didn’t seem the formidable foe.  Yet as I washed my hands, she seemed to realize I was about to do a physical exam – and was not at all happy.   For the past few days the infant had a high fever and was increasingly fussy.  With all the concern of H1N1 on the news, the mother was appropriately worried and brought her child to be evaluated.  The kiddo wiggled and squirmed as I tried to peak in her mouth, palpate for lymph nodes, listen to her heart and lungs, and examine her belly.  Last but not least it was time to look in the ears.  One of the first lessons I learned in pediatrics was to examine the ears last, as it’s the part of the exam that little ones tend to dislike the most.  I laid her on the cart, and she grabbed and pulled at the stethoscope around my neck.  With a stronger tug she probably could have given me quite a head butt!  It took the help of both mom and dad to hold her down, which only frightened her more.

I finally managed to look in her ears with the otoscope.  Her left tympanic membrane was bulging and appeared an angry shade of reddish-pink.  It was an ear infection (acute otitis media).  The child was sent home with a 10-day course of amoxicillin and instructed to take Children’s Tylenol and Motrin for pain and fever control.  With any luck, the feisty kiddo would be feeling better soon.      

This month I have been doing a rotation in Pediatric Emergency Medicine through Ohio State.  I am at Nationwide Children’s Hospital in Columbus.   As the only hospital in the region capable of providing specialized care for kids, it’s a very large facility.  With the completion of a new 12-story inpatient tower in a couple years, it is poised to become the second largest children’s hospital in the country. 

With over 75,000 visits each year, the emergency department is a bustling place.  Adding the H1N1 pandemic to the mix, there is never a shortage of patients that need to be seen.  The majority of kids I have seen are found to have some sort of infection (i.e. ear, urinary tract, or viral upper respiratory infections).   Yet the diversity of medical problems seen in emergency medicine has allowed me on any given day to help care for a child with new onset diabetes, a head injury, or appendicitis.  As a Pediatric Level 1 trauma center, the hospital commonly sees children injured in major car accidents and fires.       

It has certainly been interesting to be a student during this influenza outbreak, and seeing how hospitals have “ramped up” to accommodate the increase in patient volume.  The majority of kids with suspected H1N1 that I’ve seen in the ED luckily did not require admission to the hospital, and were sent home with instructions for supportive care.  On the other hand, at least once a shift there have been children with respiratory distress or pneumonias that required admission, sometimes to the intensive care unit.

This rotation in the pediatric emergency department is definitely keeping me busy.  I’ve enjoyed the complexity of the diseases I’ve seen, as well as the occasional “challenging” 23-pounder sporting pink puppy-dog shirts.

The start of a new month brings about another new rotation.  Just as Toledo seems to be a battleground in the Michigan/Ohio State rivalry, my away rotations are equally split.  After a month at the University of Michigan I am heading down to Ohio State.  For November I will be completing an elective in Pediatric Emergency Medicine at Nationwide Children’s Hospital in Columbus.  I really enjoyed my time in the ED at UTMC during my third year clerkship, so I’m looking forward to this upcoming month.  I have heard that Nationwide Children’s is always quite busy, and with H1N1 there will certainly be no shortage of patients. 

I enjoyed last month’s rotation in Pediatric GI at Michigan.  Even though it was a subspecialty month, I saw a great deal of general pediatrics.  I think being able to manage the common complaints is just as important as caring for the rare “zebras” that are found at large tertiary care centers.  I gained a lot of experience in evaluating the “bread and butter” of pediatrics, from growth and nutrition to constipation and vomiting.    

Stories from the pediatric ED coming soon!

My time in the Emergency Department is over and it’s off to a new adventure.  It was quite a busy weekend as I finished up my last shifts.  It’s funny that when you get off work in the wee hours of the morning, the food you crave (and the only place open) seems to always be Taco Bell.  So my friend Dimitrios and I made a run for the border.  It’s a busy place at 3 AM, with long lines of people trying to revitalize after the night’s shenanigans.

As we waited, it was fun to reflect on our month in the ED.  We certainly experienced a full spectrum of cases.  I saw heart attacks, pneumonias, suicide attempts, STD’s, and all sorts of fractures.  As the future pediatrician I tried to see as many kids as I could.  I evaluated a preschooler who was climbing up a dresser, only to have it fall over on top of her.  I was astonished to see the bright ring on the x-ray of a toddler who stuck a metal washer up his nose.  I met an infant in respiratory distress from bronchiolitis, who ended up being transferred to St. Vincent’s.  Hands down the most dramatic thing I saw was a man who unexpectedly stumbled in through the back doors, bleeding heavily from a gunshot wound.

For us medical / physician assistant / nurse practitioner students, it was fun having independence during this rotation.  I got to do the initial evaluation, order and interpret labs, and really have an active role in forming the plan of care for my patients.  It was a nice preview of what things will be like during my residency in the not-too-distant future.  So to say the least it was a great rotation, one of my favorite in med school so far. 

For the next month I’m leaving not only the organized chaos of the ED, but I’m heading out of Toledo altogether.  I’ll be doing a general surgery rotation in Kenton, which is near Lima. 

The wailing sirens and pulsating lights of an ambulance are ubiquitous pieces of modern life.  Most of us have seen a medical transport helicopter dart across the sky.  This month I have been able to see what happens after the sirens silence and the rotors stop spinning.  The UT Medical Center, along with St. Vincent’s and Toledo Hospital, are certified Level I Trauma Centers.  This means that these facilities are able to care for the most critically ill patients, involved in anything from car accidents to gunshot wounds. 

When the first responders find the patient to have a critical injury, they notify the hospital.  The overhead page begins with a loud beep (a startling, rather ugly tone, like something from an alarm clock), and the operator announces a trauma is coming in.  The emergency department quickly fills as staff from various specialties trickle in.  The gowns, gloves and masks are picked up, and the landing lights on the helipad are turned on. 

The trauma rooms are equipped with everything needed to quickly assess a patient and make life-saving treatments.  X-rays and ultrasounds can be done at the bedside.  The cabinets have supplies for procedures ranging from placing IV’s to opening a patient’s chest.  An empty trauma room seems a bit large for the lone bed in the middle, but once the patient arrives there could be over a dozen people inside at any given time.   

When the patient enters the room the rescue squad quickly relates the pertinent information (age, type of accident, treatments given).  Then the team goes to work.  Each person has a specific job to do, with many things happening at once.  One person stands at a podium to act as the scribe, recording important findings and relaying vital signs and test results.  When the patient comes in the scissors come out, as all clothing has to be cut off.  If a patient is critically injured the last thing you want to do is waste time or cause further injury trying to get off a shirt or pair of pants.  Along with the medical personal, during a trauma a chaplain or social worker tends to the patient’s family as they arrive.   

To assess a trauma patient, just follow your ABC’s. 

A = Airway          (Any fluids, objects, or injuries obstructing the airway?)

B = Breathing      (Is the patient moving air, and is this adequate enough?)

C = Circulation     (Is there a pulse?  Any internal or external bleeding?)

D = Disability       (What is the level of consciousness?)

E = Exposure       (After a complete head to toe check, what injuries are visible?)

After an assessment is made, the team then forms a plan of care.  If the patient is stable they often get a CT scan down the hall.  A CT is a thorough and relatively quick way to look at a patient’s bones, vessels, and organs.  If the patient is unstable they might have to go directly to the operating room. 

A serious injury can undoubtedly be the scariest experience of someone’s life.  Yet it is comforting to know that in the event of the unthinkable the cavalry is waiting, ready to respond. 

Well, I am writing this blog in the wee hours of a (dare I say it?) quiet morning in the Emergency Department at UTMC.  Normally I wouldn’t want to say the word “quiet” out loud, but I hopefully I won’t jinx myself by just writing it.  Too often on my rotations I have seen absolute chaos break loose as soon as someone comments on how quiet and stable things are.  Just like actors dare not say “Macbeth” in a theatre, you generally don’t want to say “quiet” in a hospital. 

I’m finishing up my third overnight shift in a row, and I think I’ve adjusted to the time change fairly well.  One thing that really struck me starting out in the ER were the types of medical problems that come in.  I saw a fair number of cases this weekend that needed immediate evaluation, such as chest pain, a broken collar bone after a car accident, and a badly broken wrist from a Nintendo Wii mishap.  However, it seemed like the majority of cases I saw were not emergencies at all, like minor colds, ear infection, and chronic knee pain. 

If you need any indication that the healthcare system in this country is broken, an emergency room is a great place to look.  For multiple reasons ERs become the sole source of medical care for certain patients.  These could be the 45 million Americans without health insurance, and those who do not have access to primary care physicians of their own.  It is unfortunate to see the amount of resources consumed in treating minor medical concerns (ER visits are incredibly expensive), but it’s even more troubling to know that the ER is all that some people have.  An ER is a great place to go if you need immediate help for an acute condition.  On the other hand, I fear what would happen if I had to rely solely on the ER for management of diabetes, high blood pressure, or asthma.    

So while I might be on my surgery rotation, I definitely can see this month in the ER as being a great review of internal medicine, psychiatry, and pediatrics too.