Medical School 2020, Year 3, Week 11

First week of inpatient pediatrics starts at 7:00 am. The team consists of a PGY3 (“senior resident”), a PGY2 (“the mid-level”), two interns (would be “PGY1”), an M4 in the role of an intern (“Acting Internship”  or “AI”), and two M3s, including me. The PGY3 pediatrics resident is a short quiet 31-year-old. He looks at the floor and around when he speaks to someone. He took several years off after college to live in NYC with his librarian girlfriend. The idea was to work as a researcher to improve his medical school application, but working as a “manny” for wealthy Upper West Side families turned out to be the job that paid enough to afford an apartment. The PGY2 is a 29-year-old Oregonian native who loves her three cats and is married to a tenuously employed man back home. Rockstar Rita is the attendings’ favorite intern. Her girlfriend is a resident in a city that is a four-hour drive away so they rarely see each other.

After meeting the team, I shadow the interns and residents on Monday while getting accustomed to the basic structure of the day. First, we preround on each intern’s 3-4 patients. The interns plus the “AI” write notes at the resident station until morning handoff at 8:00 am, packed into a 10-person conference room attended by the residents, interns, medical students, our pediatric hospitalist attending, and the hematology/oncology attending and/or fellow as well. We first go over the oncology kids. Rockstar Rita has all of these notoriously complicated cancer kids. She presents a patient summary for each of the four “regulars”: two acute myelocytic leukemia (“AML kids just get sick” [from the drugs used to destroy their white blood cells]), a rhabdomyosarcoma, and a Ewing’s Sarcoma. She highlights actionable items such as thresholds to transfuse platelets or red blood cells, when to draw another blood culture if they have a fever after 24 hours, and pain medication regimens. The night team then presents the new patients admitted overnight. Finally, we leave the conference room to round on each others’ patients in our pack of 8 and finish at the resident station for everyone to write notes.

The resident station is a short hallway outfitted with five computers that connect the nurses station with the snack room in the middle of floor. It is hidden from patient’s view but clearly not out of range from the loud conversations going on. “Alright, team lets get em out,” as he whistles. “The Discharge train begins.” Rockstar Rita complains that her “T1D” [12-year-old type 1 diabetic admitted for diabetic ketoacidosis] should be ready to leave the hospital, but is acting lazy: “She just won’t get up. She is lying in bed, not drinking or walking. This is a perfect job for a medical student [looks at me], Go get her up. I don’t care how you do it but get her to chug a glass of water.” What do we do if a patient doesn’t want to leave?” The senior resident chimes in: “Same exact thing with gastroenteritis girl. Vomiting is not a reason to be admitted to a hospital. They were admitted for concern of an appendicitis, which we have now ruled out. Go have diarrhea at home like everyone else.” The AI chimes in: “We ask him if he wants to go home and he replied, ‘No, let’s stay, it’s fun.’ Could we take the TV cord? (Oh no, cord broke what happened?)”

The senior resident added afterwards: “It sounds heartless, but we need to get these patients out of the hospital. The PICU is completely full so when we don’t have a room patients may have to be transferred to a less capable hospital. Also, the best thing for these patients is to get home and back to a normal schedule.”

I wake up our T1D, walk her to the water station for a drink, then drop her off with the video games in the Teen room. 

I then sit down with my classmate Diva Dorothy, one of the younger class members at 24. She’s a great resource now that our class has dispersed because she keeps up with gossip from every year within our school. She started a week earlier and gives me some advice about Inpatient Peds. “Unlike with adult medicine, pediatric patients recover so quickly that it’s tough to do any patient presentations. Grab any patient who will be here for a few days. Also, bring your own laptop because there won’t be room at the resident station.”

She confides her struggle during the previous week. “They think I’m lazy or not interested and ignore me. I’m sitting in the next room over and they’ll just leave and go to the consult without me. No one gave me any orientation, each medical student has had to rely on the previous medical student to get situated. We have no idea what note templates to use [within Epic]. No one gives me the AM rounding sheet showing new patients that they print out for everyone else. How did you get one?” (me: “I try to get in at least 15 minutes before the official 7:00 am start time. Then I can ask the night team resident for a printout.”) 

Dorothy: “I’m sad about this whole experience because I loved outpatient pediatrics. I’ve had such a bad time here that it’s making me question doing pediatrics.” I agreed that it is a shame that an unapproachable team during a clerkship can discourage someone from pursuing a residency. She complained last week to the clerkship director. Apparently this was conveyed to the pediatric hospitalist attendings because Dorothy remarked that this week’s orientation was substantially improved.

[Discussion with Jane that night: “all of the rotations are poorly organized.” By Wednesday, Diva Dorothy is absent. Our team is told that she is sick with a stomach bug, but she texts me to say that she has been moved to hematology/oncology clinic at a different location.]

After rounds we sit at the residents’ station. I am surprised at how little we actually see patients. After the initial morning round, most patients do not get seen by a physician until the next day. The night team does not go in unless a nurse asks them to. Residents during the day spend most of their time writing notes, ordering labs, and finishing discharge summaries. The senior resident mentioned that one thing a medical student can do to help the team is check periodically on patients. [Editor: Doctors are so busy typing at computers that the medical students have to do the actual doctoring.]

We get two new admits from the ED at 4:00 and 4:30 pm. Diva Dorothy was packing her stuff. The attending had to convince her to stay later than the normal 4:00 pm sign out. The attending: “You can go, but it would be good practice to admit a patient.” She responds: “Okay, I’ll stay.” (We are only supposed to do one late sign out per week). The residents/interns regularly stay late. 

Tuesday is a typical day. I get in at 6:45 am for prerounding on my one patient. At 8:00 am, I head to the conference room for morning handoff. Diva Dorothy is complimenting Rockstar Rita on her new short haircut. “I love short hair, but I never know if I should get it. My parents are Sikh so they frown when I cut my hair.” (She references a tattoo, though, but I have never seen it.) Once everyone is present, we hear about the cancer patients. Rita is doing a fabulous job despite constant interruptions from the PGY2. The Attendings are chatting with each other, oblivious to this rivalry between the two young women. I pick up a new patient who was admitted by the night team.

The medical student or intern present the patient to the patient and the whole team in the room. We are instructed to use “layman’s terms” or explain the term if you use it to a patient: e.g., “afebrile means no fever overnight”; “leukocytosis with bandemia means high white blood cells with markers suggestive of immune response”. The quality of our presentation is a big part of how we’re evaluating, but it is challenging to select the right amount of information for the team and the desired level of detail will vary considerably depending on whether we’re ahead of or behind schedule. One attending later complimented me after I brought up a potentially disturbing question with him privately before we entered a patient’s room. I didn’t tell him that it was Rita’s whispered idea.

I struggle to present my patient in the clear “SOAP” format [Subjective, Objective, Assessment, Plan], forgetting a few lab values and symptoms that I mention in the wrong section. I need to work on this. Much different that presenting a surgery patient. 

She’s six months old and was taken to her pediatrician for a three-day history of diarrhea, nbnb (non-bilious, non-bloody) vomiting, and lethargy. The pediatrician gave the baby some Pedialyte and sent her to an outside ED, which administered a fluid bolus (20 mL/kg). and took an x-ray to look for possible obstruction. The extra hydration led to rapid improvement in her symptoms. The x-ray did not show any signs of obstruction, but there is a concerning left upper quadrant opacification suggestive of a mass. An abdominal ultrasound showed a large, heterogeneous mass separated from the kidney and spleen. The outside hospital did not feel prepared to evaluate this patient, so an 80-mile helicopter transfer to our tertiary hospital was ordered.

[Editor: Yay! Creating jobs for East Coast Aero Club graduates and Eurocopter mechanics.]

The baby arrived looking well and entertained the residents as the cutest kid on the floor.  Morning report from a night intern: “Given the location of the mass, our differential needs to remain wide. This includes: Wilm’s tumor, nephroblastoma, neuroblastoma, lymphoma, and other neoplasms of the adrenal gland, kidney, stomach cancer, etc.” PGY2 chimes in with statistics about the most common pediatric malignancies. Our Attending: “I called down to radiology and our pediatric radiologist is not convinced this is a mass. He wants us to insert a NG [nasogastric] tube to better visualize the stomach.” The heme/onc noted that the abdominal ultrasound did not show much vascularization of the unknown mass. We need to CT before we can have a definite plan. I’d like to CT before we biopsy.” The hematologist/oncologist attending goes in and tells the parents that there is a concerning mass that may be a tumor. The parents start crying.

A few hours later, after we get through our critical note-typing, I am tapped to insert the NG tube under Rita’s guidance. Every NG tube must have a x-ray to confirm correct placement, i.e., not in the lung or perforating the stomach into the peritoneal cavity. The baby gets her second x-ray.. We send the baby down to get another abdominal ultrasound while water is poured into the NG tube for better visualization of the stomach. 

I look at the NG tube-confirmation x-ray and notice that the mass is gone. I bring this up to the resident. “Hmmm that is very interesting.” A few minutes pass and the ultrasound tech calls to say that she cannot locate the mass. We go down to the radiologist who believes this “mass” was just a distended stomach. “Look at the air-fluid levels on the ultrasound. It’s just a really distended stomach from a large feed.” We learn that mom is feeding the child 9 oz of formula every 2-3 hours, about 3 times the recommended amount.” The senior resident jokes: “We just discovered a new disease: malignant constipation.”

We have two boys on our floor for constipation requiring manual disimpaction. The senior resident: “This would be a perfect job for our medical student. Ask the nurse to supervise.” The nurse explains how to do the procedure before we go in. I perform the digital disimpaction and insert an NG tube hooked up to a Golytely solution drip for clean out. The resident joins: “Now we wait until we see yellow watery diarrhea, no brown.” The patient’s girlfriend comes in to support him. The resident explains:  “I’m explaining to the 16-year-old about how to prevent this from happening, not holding stool in, how his colon is distended so he may have some fecal incontinence over the next few weeks. His girlfriend is cuddling in his bed while I’m explaining this. Weirdest experience ever.”

This prompts our attending and the heme/onc attending to share horror stories. “I remember we had a disimpaction of a 8-year-old that resulted in such a stench that people started coughing and residents fled from the station. It permeated the entire floor..” Our attending: “My worst experience was my Ob/Gyn rotation. We had a 500 lb female pregnant woman undergoing a CS [cesarean section]. I had to hold up her FOPA [unfortunate acronym for “fat over pussy area”; sometimes FUPA for “fat upper pubic area”] where there was an yeast infection growing in the folds. Worst thing I have ever smelt. Worse that the C diff [clostridium difficile] C-section. C diff diarrhea was oozing off the OR table onto the floor.”

On Saturday, Jane and I go to the school library. She is scheduled to to give two school tours to the interviewees. We don’t recognize anyone with the new first year class. Our library is featuring 10 new book purchases, 8 of which are on LGBT health issues, e.g.,  LGBTQ Health and How to Teach LGBT Psychology. Jane, as part of her admissions committee work, gives two tours of the school to interviewees. “They think that I have no say on their application, but I am noting which are my favorites. We will use these comments for the admissions committee meetings every month.”

Jane and I have completely different schedules during the week. Jane is on her radiology clerkship, described as a “Radiation Vacation” by the clerkship director at orientation. She gets in at 9:00 am and spends two hours with a radiologist in the morning, followed by a break until 1:00 pm followed by another 2 hours. She has two morning classes and one afternoon workshop per week. “Radiologists are so deprived of human contact that when they have a captive audience they will not shut up. After 30 minutes of word vomit, I wanted to shout ‘Shut up and show me some goddamn images!!’ One radiologist explained his dream of a single payer health care system. He gave a talk on ‘relative value units [RVU] math’ and said ‘I need to read 150 x-rays and 10 CT scans to just break even.'” Jane: “We only got through two images for the entire two hours. I wanted to yell at him to shut up.”

Mischievous Mary commented at lunch: “I don’t see the long game if you want to become a radiologist. It’s like the one off-ramp for those who realize they can’t deal with other humans, but have already sold their souls to to medicine. If you never want to talk to anyone, just become a engineer or something instead of going through med school and residency.”

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 2 nights. Jane and I attend a concert in the pouring rain on Saturday evening. We learned later from Instagram that at least two of our classmates were also there.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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