Out of the mouths of babes…

Almost Dr J (ADJ): So what do you want to be when you grow up
8 yr old ADHD, ODD boy: a soldier.
ADJ: and what do soldiers do?
8yr old: kill people
ADJ: Oh. And what kind of people do they kill
8yr old: Germans.

ADJ (wtf? this kid is about 60 years too late)

ADJ: Well soldiers cant kill all of the time. What else do they do?
8yr old: push ups.
ADJ: How does one become a soldier?
8yr old: You do a lot of pushups and kill germans.

ADJ: Are there any other jobs you might like…what about a policeman?
8yr old: they are alright
ADJ: what is the best part about being a policeman
8 year old: coffee and donuts.

less than a week until match…everyone keep your fingers crossed for me

At long last my week in nursery is done.

Babies. Cute to play with, boring as all get out to examine. Although doing Ballard Scores was mildly amusing for the first day or two. Ballard scores are basically an assessment of the babies gestational age that is done on every newborn before it leaves the hospital. The scores are assessed in both neurological and physical fields.

Or as I like to call them, “baby aerobics” because the physical half basically involves shifting the babies limbs every which way. The scarf sign is how far across to the midline or across the babies arm can be shifted. If it can go all the way to the neck like a scarf, that’s not good. The square window tests flexion of the wrist, while the popliteal angle and the heel to ear test check range of motion on the legs. The scoring is fairly subjective, but the basic idea is the more flexible the baby, the more premature by developmental gestational age it is

Now before my new mommy readers start panicking, just because a baby receives low ballard scores does NOT mean it is actually premature. Babies can be born at full term but simply still have development remaining to go through. In other words, they simply need more womb.

As for the other half of the ballard, well that is checking for things like lanugo, downy hair seen primarily on babies fresh out the mama, and anorexics. Also looked for are foot creases, cracked peeling skin with visible veins (baby sitting in a bathtub for 9 months is gonna peel, yo) and two other things that are good to look for and ideal for an immature person like me to carry out

the first is ear recoil. Well developed babies, good stiff cartilage in the ears. So you flick them. Bend the ear down and watch it flick back. I could flick baby ears all day.

The other is checking for breast buds, or the “baby nipple pinch” See, since baby has been bathing in moms hormones for 40 weeks, some of that maternal estrogen crosses the placenta and newly born babies will often have slightly elevated breast buds. We basically feel for these which in a full term developed baby are usually between 1-4 mm in height. They fade away within about a month as mom’s hormones disperse.

So my week in nursery and that was pretty much what i saw. Oh except for my little viejo and my circus baby.

The little viejo was a baby who i took one look at and he appeared like an old man, ready to scream from his crib, hey you kids, get off my lawn! When i was joking with the resident and PA student about it, the attending overheard and informed me that appearing like an old man was a sign of a SGA (small for gestational age) baby. Their extra skin makes them appear a little wrinkly which combined with small size gives them an old appearance.

Look at that…i am learning to observe important things without even realizing i am doing it.

As for my circus baby while doing a routine physical and ballard I was again joking with the PA student…”time to do a baby exam…hmm ten fingers ten toes, looks good let’s go” When as i was checking the fingers i noticed there were 12. This baby had polydactyly, something which is apparently much more common in babies than i had thought, especially so among the black population. Now these fingers were pure cartilage without bone, so the standard procedure is to tie a string around them very tight, cutting off the blood supply and within a couple weeks the offending additional appendages go all necrotic and fall off.

I know i would be all pissed too, except that the kid would get no practical use out of these extra fingers even if we let him grow up with them. Aside from having a great way to start a conversation.

Now I am back in the clinics, on my last week of pediatrics, which has been by far my favorite of the 6 week rotations. Possibly one or two more peds stories this week, and then next week I start two weeks of ophthalmology, one of my final two choices for what i want to be when i grow up. (the other being internal med)

p.s. OH yeah, and greek easter, was awesome pics to follow within the week

p.p.s. I have joined twitter because internet is my crack…follow me on rveblade if you are a member!

It finally occurred to me why i like the floors more than clinic or nursery, which is what i am on now.

I have time to think.

In the clinics, due to the very nature of the clinic, patients come at you like some conveyor belt is pushing them down the production line. Insert patient into room, produce symptom description, make diagnosis, prescribe appropriate medicine or course of action, move onto next room and repeat. 15 minutes a pop.

Now of course i have more time than that as a student, and some days clinic doesnt have enough patients to feel so rushed. But on the floor, i know the patients are there for at least 23 hours. I can go back in and ask things i may have forgotten. I can let ideas i didnt even know i had simmering in my head come to a boil, ideas that could change a patients diagnoses and management. I can research things i didnt know about, in enough time to effect how i approach my patient. And if the idea i had was wrong? well barring any horrendous mistakes, the patient is still there for me to go and correct it. And sure there are the moments during a code when rapid thought and action will be required, but the floors allow the learning process to proceed at a natural pace without feeling rushed

And when did i finally come to this realization of what it is i like about the floors?

When i was on call, hanging out on the floors. So there is that learning curve in action.

…Just a thought.

p.s. I shaved again. All but the goatee is gone. pics to follow…eventually

Halfway through my pediatrics rotation, and some random things I felt i should share:

1. Little kids in little hospital gowns standing next to adult size IV poles is incredibly cute. I feel like we should make mini poles like they have the mini shopping carts. But then we would need mini nurses to bring them in. and that way lies madness.

2. Some babies are cuter than others. I am sorry parents, but it is true.

3. I do not think i managed to play with the babies nearly as often as I should have while working on the floors. Instead i used that time to study. Hopefully i have learned from my mistakes

4. I do not like the number 4

5. Some women should be out and out sterilized even before they should be allowed to have a child. Unethical? maybe, maybe not. If you saw how some of them treat their children, you might agree. And yes, sick babies can be frustrating, but 2 month olds do not have the facultative capabilities to understand “shut up, i am on the phone.”

6. You think delivering bad news to adults is bad? It is a whole other world when you have to tell a parent their child has leukemia or any other buzzword illness associated with death or cancer. The attending I admire says his tradition ever since he was a resident is after delivering bad news, hand your pager off to someone else to cover for you, and just go somewhere you can be alone for 15 minutes. Anytime his residents have to deliver such news, he takes their pagers and forces them on this brief sabbatical to just let it sink in. I hope i am fortunate enough to have such people to work for, and with when i am in residency

7. I am finished with working on the floors, and now begin two weeks of outpatient peds clinic, followed by 1 week of nursery. I am going to miss the floors, as i generally prefer them to outpatient clinic. Still not sure why, but at this point in time, i simply enjoy being in the hospital, even when i dont like it.

8. Stereotypes are based in truth. Hate me for saying it, but you cant argue. That has just been driven home time and time again working at this particular community hospital.

And i am tired of making a list. Just a few words to those of you who have been following along since i moved to xanga almost 5 years ago now. Thanks for reading, commenting, and subscribing. I have changed my writing style and gimmicks quite a lot in the last 5 years, and i dont know how some of you found me, or why you keep coming back, but I appreciate it.

In other news, I am gearing up to give this site a major overhaul in the next year when I finally graduate and get that fancy degree for which i am going to school. So the question I pose to you is…do I rename the site from Look! A Decoy!, or do i open up a new site exclusively for residency and beyond? And if so, would you follow me to a mostly medical based weblog, or would you prefer my usual antics (which have admittely been less anticky of late)

Discuss. I still have time, though sometimes it feels like it is all bearing down on me too quickly.

and yeah, still not planning on going into peds-like the kids, cant deal with parents

Today I performed a surgery. Yes. Me. Under the strict supervision of an attending, but basically he walked me through what was a fairly simple procedure. But let me go back to the beginning.

The patient was an 8 year old boy with encopresis. Yup, another kid with backed up poop. Knowing of my interest in GI (and my ability to speak spanish) the resident assigned me to the case.

Rather than a dismpaction, it was decided to go a more surgical route. The rationale behind this was unlike the other patient, who was presenting with the problem for the first time, this patient had been previously diagnosed and had this as a recurring problem for several years. Conservative medical solutions had already been attempted.

So the plan was for a colonoscopy with percutaneous cecostomy. Basically, his entire colon would be cleaned out, and then a small hole would be poked in the abdominal wall directly into the cecum (the earliest part of the colon) and a tube would be passed through the colon which could then be flushed with laxatives to give the kid an anterograde enema. (anterograde-in this case, from the stomach down, instead of the anus up)

So when the gi doc came to evaluate the pt, i asked if i could accompany him on the procedure. He agreed and off we went to the OR.

It was just he and I, no resident, so right off he had me doing a lot. I inserted the scope and while he focused and looked at structures, i was told to advance or retract the scope, which by the way worked itself up a good 65cms into the colon. That is a lot of pipe to have up your butt. ALong the journey, we made frequent pit stops to irrigate the colon of the poop locked inside it. Most of this was able to be irrigated, but some had to simply be pushed down by the water to where I could reach in and grab it from the rectum. This was by far the longest part of the procedure, cleaning the bowel, all the way making conversation with the attending and anesthesiologist.

About 2 hours later, the bowel was finally clean and the attending rotated the scope so the stomach was transilluminated. Basically, the light from the scope shone through the skin so we could see where to place the needle from the outside, a tiny little circle of light from the scope marking the spot. The needle was placed through, and then i was handed the scalpel and told to make 2 small incisions on either side of the needle to widen the cut. Words cannot describe my thoughts or emotional state at that moment…if i am lucky, i will have many opportunities to feel similar when i start practicing medicine. Cheesy, but true. I placed the cuts with care and precision, and then i ran a guidewire through the now hollow needle where the attending caught it with the snare function of the scope, lassoing it into place. As i fed the wire down, he retracted the colonoscope until finally the wire exited the rectum and there was one end of the wire at each end, so to speak, of the child. Next, a hollow tube, or gastrointestinal tube, was placed over the wire and then the wire was brought back up toward the colon with the g-tube on it until it setteled in place at the cecal valve, the bodys entrance to the colon. Then the wire was removed, along with the colonscope, and the incision was cleaned.

The attending followed it up with, well doctor, you did the surgery, you write the post-op note. Scut i certainly didnt mind. He had me come up with the post op plan, and then added many things i had forgotten along with several i would never have thought of.

For the next several months, and possible the next year, this child will receive a daily osmotic laxative in the evening through this g tube. Water will rush down his colon and distend it, propagating a signal to the rectum and anus to contract the appropriate muscles to defecate. Essentially his colon is being retrained for when the tube eventually comes out and he is continent again.

**After excitedly telling this story to a friend, she brought up the point that it seems like i already know what i really want to go into. I have been having an agonizing time trying to decide if i want to do optho or internal med, mostly because optho is an early match, and if i match and change my mind, or hate it, i have no choice but to stick it out for at least a year. And that is why i am doing an ophtho elective in may, to see once and for all if I like the doctor side of ophtalmology as much as i enjoyed the technician side working in undergrad. If i can have the same kind of passion about the eye as i seem to have for the digestive system, then it will alter my 4th year schedule as i shoot to apply to ophtho. If i do not like it, or I enjoy it but not with the same fervor, then i can contentedly continue down the path to internal med.**

DISCLAIMER: THIS POST IS NOT FOR THE SQUEAMISH AS IT CONTAINS MANY MANY USES OF THE WORD, POOP. THANK YOU.

Ah into the wonderful world of pediatrics, where a sense of smell can definitely hamper your ability to effectively practice medicine.

My first patient was a 10yr old male with a 7 year history of ADHD, and fecal incontinence with soiling (pooping his pants unexpectedly) He had been a normal vaginal birth, met all appropriate developmental milestones, including toilet training, when suddenly about age 3, the mother noticed he would simply have uncontrollable bowel movements and soil himself. SThis happened every day, with approximately 2 of his 4 bowel movements per day, where the pt would feel the urge to go, and then defecate before having enough time to make it to a restroom. Stools had no blood, and were normal in color and consistency. She then took him to several doctors, all who told her he was doing it for attention until she finally reached our hospital where we decided to take a closer look.

On physical exam, the pt was an active cooperative male child. Vitals were within normal limits and physical exam was uneventful except for a hard mass in the right lower quadrant and suprapubically

Our working diagnosis is encopresis with fecal impaction and constipation.

So you may be wondering how one can be constipated for 7 years, and soiling their shorts at the same time. Or maybe you just dont know what encopresis is…

Basically, at some point in his development (probably a little before age 3) poop started to build up in his colon, as in he was not dropping all the kids off at the pool, but leaving a few in the van. Now the colon serves to remove water and bicarb from your digested food, leaving behind a mostly solid mass of unusable nutrients (aka poop). As the years went buy, the undefecated poop continued to back up and have even more water removed from it basically turning it from a log into a tree. Or more specifically, that mass felt in the abdomen was solid poop backed up all the way into his gut. This was confirmed by x-ray

This kid was quite literally, full of shit

So the plan? First, laxatives and enemas. Not because either of these will clean out seven years worth of congealed poo by itself, but it will soften the stool up and clear out some loose pieces as he is prepared for …DISIMPACTION.

Ah yes, disimpaction, where the pt is sedated with ketamine (pain control) and midazolam (relaxation and slight amneistic effects) as some lucky resident or medical student gets to reach a couple fingers into the rectum and scoop out the fecal matter bit by bit, with another hand on the stomach to move that log down as it is continuously dug out.

Sadly, (and i really mean this) I could not stay to observe or assist, as i had to go to a lecture

but the most disturbing part of this whole case?

How in the world is a 3 year old diagnosed with ADHD?