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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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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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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I’m pretty convinced a big plus of going into the surgical or emergency medicine fields is the stories that you get out of it. Blatantly stolen from an attending:

“You wouldn’t believe the kind of lies people make up when they present to the ER with something stuck up their butt. My favorite? A man comes to the ER with a zucchini up there, and proceeds to tell me, ‘Yeah, I was gardening naked tonight at home when I fell backwards and it got stuck up there.'”

Another hint from the attending–“If you ever get a votive candle stuck, don’t just pull on the wick. It’ll come right out, because your body has warmed up the candle wax, and you just won’t get anywhere.”

I’m tellin’ ya. It’s all about the stories.

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Even though it’s sometimes hard to see a patient as more than just their disease, I’ve really started to think about how this is, for most people, just a tiny little part of their life. You forget that you’re seeing a patient at their worst–sick as stink, post-operation, and feeling crummy. They haven’t showered in days, they’re eating crappy hospital food, they’re too weak to do more than lay in bed most of the day, and they’re away from their families, their cultures, and their homes. Sometimes they’re unconscious, or so drugged up that they’re not even with it. And because this is almost all you see of the patient, it’s not uncommon to make what’s called the fundamental attribution error in psychology–believing that a person’s actions or behavior is due to the patient’s own personality than it is due to the situation he or she is in.

Even in clinic, seeing the patient before they’ve had any sort of procedure or treatment, the attribution error can stick. The clinic is usually running late, so the patient has been waiting for awhile; he or she is probably nervous about seeing the doctor and learning what kind of treatment will be necessary (especially when they know they’re in a surgeon’s office for a reason); he or she might not be feeling well, and any other number of reasons. So if the patient (or a family member in the room) is crabby when I enter the examination room, I automatically assume it has nothing to do with me or the other person. I’ve learned to take no offense. I automatically give the person the benefit of the doubt. It’s not uncommon for patients to get a disappointed look on their faces when I enter the room anyway–they’re expecting to see the surgeon, and then I introduce myself as “the medical student on the team.” (I do think, however, they are slightly relieved to find out that someone as young as me will not be performing the operation.)

This all came about because of a sick-as-stink patient we’ve had on our service recently. He’s been in and out of the ICU, unintelligible when he attempts to talk, and pretty much out of it–due to his own neuro issues or the psych drugs we give him to keep him calm. (He’s been pulling out his drains.) One day, however, I guess a family member must have brought by a little collage of photos of the patient and his family. I couldn’t believe it was the same man. Him as a 30 year-old with his wife. Him in his 40s riding a horse with his daughter. Him with his extending family at a 50th birthday party. Scanning from picture to picture, none of them matched the dehydrated, sickly, wasted man lying in the bed next to me. All this time I had thought of this patient’s life as culminating in his surgery, cancer, and hospital stay, and I hadn’t even realized it. The egotism of my idea of the man blew me away.

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Although I’m spending countless hours in the hospital with little thanks or appreciation, the ice machines here rock. That is all. Back to your regularly scheduled programming.

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Working in a hospital with so many highly-educated patients that seem to know more about their diseases than we do, I think we probably run a greater risk of making assumptions about our patients’ education, intelligence, and vocabulary.

Many times I’ve noticed doctors, even when trying to explain things in “English” (as opposed to medical-ese), start using terms like “distal” and “proximal,” and patients start to get a look of confusion on their faces. I try my best to stick around and explain things better to the patient, but many times I don’t even think we realize we’re doing it. Even words like duodenum and common bile duct I would imagine could be very confusing. I assume that most patients have heard of the liver, the intestines, the stomach, and the pancreas, but don’t have a clue how they’re connected, where they are, or what they do. This has nothing to do with their intelligence or ability; they’ve just never felt the need or had the interest to learn. Many were probably never taught about them.

I’ve been thinking about carrying around some pictures of the abdomen to show them to patients and explain their problems and the surgical procedures to correct them. It’d probably go a long way to making them feel a little bit more in control of their care and their bodies.

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