I totally ruined the last post with my humor-cum-neurotic antics. So back to the difficulties in examining pediatric patients.
The whole “take a good history and physical” mantra kind of goes out the window when the human you’re trying to help doesn’t do that whole
“talking” thing or that whole “sitting up” thing, or especially the “can you do what I’m asking you to do” thing. It really
makes you hone your ability to draw conclusions from limited information and to use tricks to get the information you need. A couple things I’ve picked up (post
yours in the comments!):
Checking reflexes requires the patient to relax their joint, but it’s a tough sell on a squirming infant. Even distracting them doesn’t always work.
“Follow my finger” to check eye movements can be tough. Following a toy or a face seems to be much easier.
Use the parent. They can soothe the savage beast, and keep the child’s attention while you’re busy poking and prodding them. Plus, they’re usually
all you’ve got for the history, if the kid’s too young to talk.
Let kids see your instruments before you use them. Makes them less scary. Warning: the hyperactive children will throw your reflex hammer, and may almost hit a nurse
in the eye. Keep instruments away from them.
Get on the child’s level. You’re much less intimidating there.
Other tricks, my medblogging colleagues?
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This just in: it is certifiably impossible to walk into a room with a smiling baby without your maternal or paternal instinct immediately raising the pitch of your
voice at least two octaves. It is simply uncontrollable.
The first week of my neurology rotation was incredibly dry. It consisted mostly of library time, awaiting the consults that never really came. The week was slow, and
seeing as though it was the first week, I naturally felt stupid, frustrated, and lame for asking seemingly obvious questions. After a nice mature little internalized
tantrum last Sunday (“I hate neurology! This is so stupid! Waaah!”), things are starting to make sense and get busier. Not a
whole
lot of sense, but plenty busier.
The problem with all of this, however, is the selection bias. Because only the really sick people end up in the hospital, you get a very skewed view of the
population. While most of us will remain fairly healthy throughout our lives (minus some high blood pressure, high cholesterol or weight problems), the medical
student and the resident see the worst of the worst. Since every patient we’ve seen so far in the hospital has been for a seizure workup, I’m thoroughly
convinced that every child has had a seizure in their lives. (Time out for reality: a febrile seizure occurs in 2-5% of the population, but 2/3 of those kids never
have a second seizure, so neurologists don’t generally get their panties in a bundle about a first-time seizure assocation with fever. Then again, 80% of
neurologists prefer boxers to panties, so pantie-bundling isn’t all that common among neurologists, anyway. Surgeons, however…)
So I’m somewhat convinced that I had a seizure, and my parents are keeping it from me. That, or the old evil babysitter they hired named Alva Camp that made my
brother and I eat only rice cakes and choose between taking a nap or cleaning our rooms while they chilled in Barbados just never told them about it. (And they say
psychiatrists’ children are neurotic. Clearly I’m an exception to the rule.)
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Pardon the dust, won’t you? A new design is on its way.
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The Moral Hazard Myth
is written by Malcolm Gladwell, and he takes his own quirky look at the health care system. I couldn’t agree more, Malcolm.
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on The Moral Hazard Myth
I’ll take “Signs I’m Now On Neurology” for $800, Alex (via IM to my friend Mike):
Mike: want to come have some beers tonight?
Mike: or do you have to work early?
Me: oh. i would, but i need to clean my room and try to find my reflex hammer.
Me: that’s like the lamest excuse ever, but it’s true.
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The VA is the scariest of all health care systems–it’s paid for and
run
by the government! It probably has the efficiency of the postal service and the compassion of the military, right? You might be surprised. On many screening measures
and actions shown to improve outcomes,
the VA’s winning
.
Another piece from US News
:
Three summers ago, Augustin Martinez’s skin was yellow. He was in pain. And physicians at Kaiser Permanente, his usual source of care, were baffled. The
frustrated Martinez, a retired Lockheed Martin engineer in San Jose, Calif., asked his brother, a New York physician, for advice. After consulting colleagues, his
brother advised him to go to the Department of Veterans Affairs hospital in nearby Palo Alto. Martinez, a former Navy petty officer 2nd class, was entitled to VA
care (eligibility depends on several factors, including date and length of military service, injury, and income). But his brother’s recommendation took him by
surprise. Better care at a VA hospital? But he went–and was quickly diagnosed with pancreatic cancer by Sherry Wren, chief of general surgery, who operated on
him within days. He has relied on VA hospitals and clinics ever since. “They run a good ship,” says Martinez, now age 72.
Yes, it’s just an anecdote. But Dr. Wren is a mentor, and they definitely run a good ship there.
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I’m a little worried it’s my institution (and former members of the team I’m on) that
this woman rightfully complains about
in the NYT yesterday. (I only say this because the woman is from a nearby city, and our service does a lot of breast surgeries.) However, in none of my experiences
has anyone done anything remotely similar to what the patient describes:
Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital
room.
Without a word, one of them – a man – leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.
Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, “Well, good morning,” a quiver of sarcasm in her voice.
But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical
students in their 20’s, stared at Ms. Duffy’s naked body with detached curiosity, she said.
After what seemed an eternity, the doctor abruptly turned to face her.
“Have you passed gas yet?” he asked.
“Those are his first words to me, in front of everyone,” said Ms. Duffy, who runs a food service business near San Jose, Calif.
“I tell him, ‘No, I don’t do that until the third date,’ ” she said. “And he looks at me like he’s offended, like
I’m not holding up my end of the bargain.”
I’d be just as upset as this woman if I was treated that way in the hospital. On my service, we always knock before entering a room, we greet the patient, we
tell the patient what we’re about to do (“I’d like to take a look at your incision”), and we always cover a patient of any area that
doesn’t need to exposed. Any time we remove a part of a patient’s gown, we make sure to close the curtain in the room.
Also, our teams are two medical students max–not half a dozen.
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Turned 25 today. Pretty damn uneventful. Me, internal monologue style:
Wake up, groggy.
Ugh, it’s 5am.
Look at phone.
No one called. Sad.
Oh, wait, you went to bed at 9:30, and the bf called at 10:10. You barely remember the conversation, but you’re sure he was sweet.
No one else called. Sad.
Oh, wait, it’s 5am. Who would be up this early, and even if they were, would they expect me to be up this early?
Get in shower.
Put shampoo in hand. Hey, it’s your birthday.
Joy. Rapture. 25. Car insurance now cheaper.
Finish shower. Get dressed.
Two days left of surgery, and on Monday I’ll start with Neurology. My, how time flies. Down to LA this weekend for a birthday celebration. A little delayed
gratification is always good now and then. Especially when you have a scary surgery exam in two days and have no idea what to expect.
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My dad’s a psychiatrist. Ever since I can remember, I would always see pieces of paper laying around the house in a certain configuration: 8.5×11 inch
sheets, folded length-wise and width-wise, with a pen clipped to the top. I always found this to be an incredibly strange thing to have with you at all
times–one might be in our computer room where he often works, whereas another might be next to his nightstand; you could probably find at least one or two more
on the dining room table, where he unloads his pockets after work.
Now, of course, I find myself taking blank pieces of paper, folding them length-wise and width-wise, and then clipping a pen to the top. I don’t think I ever
really noticed myself doing this until I started reminding myself of my father. The secret? You always need to be carrying a piece of paper and something to write
with, and it’s the best configuration to get it to fit nicely into a shirt pocket. Even when I’m scrubbed in on a case, I keep the paper in my chest
pocket for after the case.
So just to clear things up–you’re not a weirdo, dad. Just a doctor. (Okay, maybe you’re still a weirdo, but not for the paper-folding reason
anymore.)
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