The Medical Apprentice

My four weeks in the Pediatric Intensive Care Unit flew by, and once again I find myself on a new rotation.  I had an amazing time in the PICU at Toledo Children’s, so I’m a bit bummed to be leaving.  This month I am doing pediatric GI, working mainly in outpatient clinics.

One big difference about working in the outpatient setting is that I won’t be on-call.  I definitely enjoyed taking call, despite the havoc it sometimes wreaked on my sleep cycle.  It seems that my best “lightbulb” learning moments and most interesting patients from my clinical rotations have always came in the middle of the night.  The hospital is definitely a different world after dark.  The wards seem deserted and are eerily quiet.  My fellow acting intern Dusty and I were on-call together a few nights.  It was cool to be able to bounce ideas off one another regarding our patients or partake in the cafeteria’s amazing late-night taco bar. 

Almost every night I took call the unit received a patient with a familiar story.  While in high school, I remember helping to fill up my grandmother’s pill containers each week.  It had seven compartments marked Sunday through Saturday to help her keep track of her medicines.  While this is a great organizing tool, there were quite a few nights when I saw the potentially devastating effects when children got ahold of them.  We saw little guys admitted for suspected drug overdoses, and their stories were similar.  A parent walked back into a room to find a chair pushed over to the kitchen counter, half-empty bottles of medication on the floor, or a child who simply said “I ate the purple ones”. 

The thought of two-year-olds consuming large amounts of multiple medicines is certainly a scary one.  However, strictly from an academic standpoint, working up patients for drug overdoses is pretty interesting.  The pills in question treated some of the most common “American” medical problems (pain, hypertension, diabetes, anxiety).  Each one tweaked the body’s physiology to provide its effect.  When evaluating an overdose you have to look at each medicine and understand how it works.  What is the mechanism of action?  What is the drug’s half-life? (aka how long will the drug be in the body?)  What organ systems will be affected by toxicity, and how should we monitor for adverse effects?  These impromptu pharmacology reviews were really important to deciding a plan of care.  I made plenty of late-night calls to poison control to ensure that we were covering all our bases.

Luckily the kids I saw those nights had good outcomes.  Most of them stayed in the unit for observation and were sent home the next day.  With these cases I saw firsthand the importance of keeping medicines and other chemicals locked and stowed away from kids.  The average family medicine cabinet can provide remedies to almost every illness under the sun.  For little guys this stockpile might look like a colorful mix of Jelly Belly’s, but accidental overdoses can have disastrous consequences (not to mention the purple ones don’t taste like grape!)

The phlebotomists did not know what they had coming.  He was small but feisty.  My little brother Mike and I (5 and 7 years old at the time) had just visited our pediatrician for a check-up.  My brother unfortunately had to get a blood test.  Since needles and five-year-olds don’t generally mix well, there wasn’t anything quick or easy about it.

We walked over to the lab. My mom led my anxious brother back to the room, leaving me in the lobby to catch up on the latest edition of Ranger Rick.  I barely made it through the first pages when I heard my little brother’s disapproval.  There was loud screaming and crying followed by a burst of commotion.  My determined little bro had somehow evaded the needle’s poke and made a break for it!  His escape took him as far as the front desk before he was scooped up and carried back into the room.  The cavalry was called, and it took three nurses to hold him steady.  The screams echoed through the lobby.  The waiting patients had wide eyes and nervous smiles as they undoubtedly wondered what torture was taking place down the hall.  Finally they were able to successfully draw the blood they needed.  My brother emerged with a taped piece of gauze as the only evidence of the struggle.  His face was bright pink and puffy from all the crying.  Going to the doctor traditionally earned you a sucker, and that day my little bro came out clutching the entire bag!

When caring for adults on the hospital wards, daily labs are quite common.  They can be useful in tracking a patient’s anemia, electrolyte balance, or kidney function.  It seems a bit easier to convince adults of the importance of the occasional unpleasant hospital experiences, like blood draws or diagnostic scans.  The hospital experience for a child can be incredibly scary.   There are beeping machines, medical instruments, and strangers wearing gloves and masks.  For little ones this can be a living nightmare, so it’s no wonder why kids get frightened (and occasionally run away from phlebotomists!)

What strikes me most about the pediatric hospital experience is the commitment to keeping kids safe, relaxed, and entertained.  From doctors and nurses to social workers and therapists, it seems that everyone is focused on ensuring children and their families are comfortable.  In the Pediatric ICU all the scary medical equipment is still there.  But you’ll also find plenty of toys, movies, and videogames.  This commitment to comfort also means diligent efforts to minimize needle sticks and other scary moments.  Obviously some of these are necessarily evils (like lumbar punctures to evaluate for meningitis).  However, it has been refreshing during rounds to think about exactly which tests are necessary for determining the plan of care, helping to minimize discomfort.  From Sponge Bob to chocolate ice cream, little things can go a long way in making the hospital less frightening for little guys. 

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Speaking of needle pokes, I got my flu shot this past week.  Remember that this year there are two shots, the seasonal flu and upcoming H1N1 vaccinations.  Flu shots are important, especially for healthcare workers.  An infection that might give me relatively mild symptoms could cause a potentially devastating illness for others I come in contact with.  If you haven’t had the chance, be sure to check out the university’s H1N1 influenza website.  It has a great deal of information on what you can do to stay healthy this flu season.

Growing up, my street was on a bit of a hill.  It was annoying to lose a ball into the road and have it stop rolling a dozen houses down.  Learning to ride a bike was especially challenging.  During the training wheel transition I had plenty of near misses (and full-blown crashes) with trees, fire hydrants, and mailboxes.  Though I got plenty of scrapes and bruises along the way, in the end I somehow managed to master the two-wheel art. 

This week I’ve felt my educational “training wheels” begin to loosen.  My classmates and I submitted our applications for residency, and some have already started to receive invitations to interview.  This month I am doing an acting internship (AI) in the Pediatric Intensive Care Unit (PICU).  AI’s are chances for 4^th year students to assume the roles and responsibilities of 1^st year residents (aka interns).  We have the opportunity to manage a larger number of patients and be more involved in the day-to-day plan of care than a student normally would. 

I’m working in the PICU at Toledo Children’s Hospital.  At first I was a bit nervous about starting in an area that took care of the most critically ill little ones in the hospital.  It certainly felt like I was jumping into the deep end of the pool.  However I’ve managed to stay afloat so far and learn a great deal.  The majority of the kids I saw this week had respiratory problems including pertussis, croup, and status asthmaticus.  Fortunately I was able to see most of the little whoopers, croupers, and wheezers improve enough to leave the unit.

As a student it seems I am constantly reminded of how “green” I remain in many areas.  I wrote almost all the orders for my patients this week, with an attending physician co-signing them.  While there are plenty of equations and protocols for calculating fluids and medication doses, so much of practicing medicine is based on experience and that clinical “gut” instinct.  Is this child ready to be taken off continuous aerosol treatments?  Should I recheck his potassium level in 6 or 12 hours?  Do the steroids alone account for this high blood sugar?  Luckily I have gotten some great practical advice from my preceptors and some tremendous nurses.  Perhaps realizing just how much there is to learn is the most authentic “intern” experience one can have.

I’m glad to have this acting internship to give me a preview of what residency will be like.  There’s a mix of exhilaration and a bit of terror that comes with removing training wheels.  I look forward to what this month has in store for me (while hopefully avoiding wayward trees or fire hydrants in the process!)