My week in the nursery starts at 7:45 am. My attending, a specialist in NAS clinic (babies born addicted to opioids from addicted mothers), strolls in at 8:15 am. After residency two years ago, she did a fellowship in pediatric palliative care, and took the job at our institution expecting to be mentored by the palliative care team. However, the position evaporated, and she took the job in the nursery instead. “I needed a job,” she explained. “The goal of this week is for you to become comfortable being around a baby.” She goes over a basic newborn exam on newborn baby in the nursery receiving phototherapy for jaundice. “Tomorrow we’ll give you a newborn for you to follow. Today just follow me around.”
Afterwards, she catches up on the computer while I configure my Epic with all the best screens to view weight changes, bilirubin values, feeding schedules, and diaper changes. The 35-year-old PA student training with us arrives around 10:00 am, and I help set up his account. We then go into a conference room. She hands us a folder that every mother gets when she arrives on the floor. It includes information on breastfeeding and postpartum blues information. She also hands us a H&P (history and physical) form where we record all the patient’s information for handoff to the night team. She asks us to introduce ourselves.
The attending does newborn checks on the four babies born overnight and this morning. Around 11:30 am, she sends us over to work with the lactation consultants. They instruct us to read a packet, titled “Breastfeeding for Dummies”, describing good breastfeeding technique and detailing the number of times a baby should feed in the first week of life. After 30 minutes, we each follow one lactation consultant. “No, no, no. That must be painful.” she explains to a mother, showing her how to get a good latch. “If it hurts at all, you need to start over. Babies are lazy, you need to teach them good habits from the beginning or it will be harder to breastfeed.” She breaks the latch with her finger, and then grasps the areola with her palm, opens the baby’s mouth and shoves the breast into the babies mouth. The mom exclaims, “Wow much better.” Are there any male lactation consultants? “I’ve been doing this a long time and have never worked with one, I think I saw one at a conference, but he may have been a doctor.” [Editor: Perhaps this male-appearing individual identified as a woman?]
The next patient is a baby who is not gaining enough weight. The pediatrician put in an order for formula, but the mom wants to breastfeed exclusively. The lactation consultant disagrees with the order, but shows the parents how to feed with a syringe and tube on which the baby will have to suck. “If you start the bottle this early, the baby will start to only want to use the bottle. You’ll have to pump all the time, but your supply will slowly go down. You need those hormones to kick in to keep the supply going.”
Our attending is trying to work her way down from 180 lbs. with salad and sends me out to grab lunch with Jane at the hospital outside the coffee shop. Jane is on her orthopaedic elective. She was in clinic this morning, and arrived at the hospital two hours early for her first OR case. Jane hasn’t done surgery yet, so I give her the basic tour of the OR, the various staff members in the operating room, where to get gloves, and how to help the nurses. “Make sure you wear a mask into the OR!”
After lunch, I watch the attending perform two circumcisions. The nurse grabs a chair and puts it behind me. “If you feel queasy, sit down.” A medical student last year passed out during the procedure. I give the baby sucrose (“Toot Sweet”) drops which help the baby ignore the pain. “It distracts them.” I squeeze the sucrose tube so hard that the entire tube is emptied by the end of the procedure. The nurse laughed: “That usually lasts their entire hospital stay!” The attending does one later in the afternoon demonstrating the World Health Organization technique to the residents. It’s definitely less efficient. I learned that a circumcised infant has a 1 in 1000 chance of a UTI in the first year of life compared to a 1:100 chance for an uncircumcised boy.
The PA and I leave at 1:00 pm for lectures in a nearby outpatient clinic lecture room. We have students present a 10-minute topic of interest followed by a 3-hour discussion on failure to thrive (“FTT”) led by the clerkship director, an 50-year-old pediatrician. She talks at the speed of light. We learn that she lives with her mom in a small apartment complex next to campus known to us graduate students as the party apartment. She tells us about yelling through the window at kids swimming in the pool without a parent present. “My mom tells me to stop, but I can’t help myself. I just can’t. What parent would leave their kid alone in a pool? Right, Right?” Southern Steve counts the number of times she says “Right” — 54 times in 3 hours of lectures.
Pinterest Penelope presents on the causes of hypoglycemia (low blood sugar). The clerkship director interjects: “What is the number one cause of hypoglycemia around Christmas time or New Years?” Blank stares. “Alcohol ingestion.The kids get up early and drink all the eggnog left over. [excess alcohol consumption increases insulin secretion, decreasing blood glucose levels.] We have lots of these patterns. Halloween is DKA season [diabetics eating too much sugar]. Halloween is also costume dermatitis season.”
Our clerkship director strays from the advertised topic of FTT. “We are so spoiled with vaccines. I’ve been in practice for 18 years. My mentor would tell me how they used to go into the hospital with 100 kids, and leave with only 30 on some days. That’s how bad HiB [the Haemophilus influenzae type B bacterium] was. It would decimate entire counties. The medical community worked hard to develop HiB vaccine. I was around when Prevnar 13 was developed from Prevnar 7. I had babies die from Strep meningitis.”
A student asks: “How do you deal with parents that refuse vaccines?” She explains: “Being a doctor means dealing with difficult decisions. Get used to it. Some practices refuse to see patients that do not get vaccines. If you see a nonvaccer baby, you’ll get sued by another patient who catches measles in the waiting room or if the child dies from a vaccine-preventable disease you’ll be sued cause every dead baby is a lawsuit. We have a large refugee population here. [Editor: Maybe the next caravan from Honduras will take refuge around the pool in mom’s apartment complex?] We need to take care of them, but they are all not vaccinated. Do we just refuse to see them? Where do they go? Well they come to us, we take everyone in the community. Everyone is different, but I love this part of our job.”
Wednesday starts with patients at 8:00 am and then presenting three babies to the attending. The first baby was found to have agenesis of the right kidney on prenatal ultrasound and, during the newborn exam, was found to have a sacral dimple. We take the baby down to get an ultrasound of her spine and her abdomen.
The PA asks why? I respond: “I think it is because of the VACTERL association (Vertebral abnormalities, Anal agenesis, Cardiac abnormalities, TracheoEsophageal fistula, Renal agenesis, and Limb defects). A baby with one of these anomalies has a much higher risk of another congenital defect.” We order a genetics consult to help us rule out any syndrome. The nursery turns out to be mostly a filter for identifying complicated babies that are sent for further evaluation.
The ultrasound exam takes about 30 minutes because of the newborn’s difficulty.
Several hours earlier, the mom had asked that the baby be moved to the nursery so that she could get some sleep. I go to ask if she would like the baby returned to her room for phototherapy. “Yes, please.” No one had been to see her for hours, so she’d never had a chance to ask for the baby back. I’m surprised how docile patients can be, afraid to ask for more information from the nurses and doctors. I ask, “Has anyone explained the ultrasound results?” She responds, “No.”
“Well as you were told a few months ago [at the 20-week anatomy scan],” I begin, “your baby doesn’t have her right kidney. We want to make sure she doesn’t have some other anomalies that can occur with this. It is possible this is an isolated finding. We are getting a genetics consult to rule out any syndrome.” She was really calm and relaxed about the whole ordeal.
After lunch, the attending invites us to go home, but I decide to wait around for the genetics consult. I fill the hours until 5:00 pm by taking notes on “High Yield Pediatrics” by Emma Holliday Ramahi, a slide deck of everything relevant to a pediatrics clerk. I shared the link on our Peds clerkship GroupMe, receiving six hearts. The geneticist still hadn’t show up, so I went home.
[The geneticist ultimately arrived at 7:30 pm and ordered genetic testing to rule out some rare syndromes. I opened the check a week later and found that the patient was discharged without any further abnormal findings.]
Jane is not enjoying the first week of her orthopaedic surgery elective. She is working with a new spine surgeon. “All he wants to do is operate so he is quite brisk with the patients in the office. He’s probably a great surgeon, but I am not in the OR until next week.” What does the surgeon do if they’re not in the OR? “He has clinic three days per week and sees 50 patients per day, including post-op follow-ups. Out of roughly 25 evaluations, he might select 5 to have surgery.”
She describes the orthopaedic lounge: “They talk about sports all the time. And the female pediatric orthopedist leads the conversation. She would’ve been the center of every fraternity party doing keg stands back in her day.” Jane is frustrated about the uncertain schedule. “We have no scheduled free time that we could use for studying, but a lot of time is wasted waiting around.”
I attend dumpling-making night with a few Asian classmates. Our vice president, Sleek Sylvester recounts his experience on OB/Gyn, specifically Maternal Fetal Medicine [MFM] service. “MFM has a pretty sick gig. They just consult for the obstetricians— confirm normal fetal growth or diagnose weird condition. They have no patients they are on call for. He described his week: “I work with the ultrasound techs a lot. We noticed this one kid… ” Ditzy Daphne, a classmate who can regurgitate Anki decks, but is slow at applying the information to a patient case, interrupts: “careful what you call the fetus.” Sylvester continues: “fetus sorry. Anyways, I know nothing about reading an anatomy ultrasound. But even I could see that this fetus did not have a normal arm. The tech zoomed in on the extremity. I suddenly realized that the extremity ended at the olecranon [elbow] and it had one small digit coming off of it. We could clearly see the fully formed single finger — with the MCP, PIP and DIP. It was moving! I looked at the tech, and wanted to say, ‘What the Hell?!?” The tech just nodded her head. When we left, I was like what the hell was that. She replied, ‘That was an elbow finger. I’ve only seen one other in my career.'”
Sylvester explained that the MFM attendings receive a live feed from the ultrasound machines. “We were doing an ultrasound on a woman told she was having a female child. We kept focusing on the groin area of the fetus because we saw a scrotum but no penis. We went to the attending who asked, ‘Why were you guys looking at the scrotum so long?’ The ultrasound tech replied, ‘Because she thinks she’s having a girl.’ The attending responded, “Hmmm, well no. That’s a boy with a micropenis. I’ll go talk to her.’ He went through the ultrasound with the patient from head to toe in a very methodical manner. At the very end he showed the scrotum and nonchalantly mentioned this is a boy, not a girl. Never expected to wake up and see a micropenis.”
Ditzy Daphne added: “I had a pretty terrible time on OB. They didn’t let me do anything, and I always felt unwanted.”
Sleek Sylvester shared “[Ortho Oliver] has been telling me how bad his OB rotation is. The OB resident he is following [High Horse Haley; see Year 3, Week 13] won’t tell him when she sees patients. When he catches back up with her in the lounge, she’ll say she is too busy while looking at eBay and Amazon clothing. She neglected to tell [Oliver] that they were starting rounds and skipped him when doing his assigned patient.”
Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 1 night (the dumpling party).
The rest of the book: http://fifthchance.com/MedicalSchool2020