The last week of inpatient pediatrics is shortened by Thursday’s Shelf exam. I am woefully unprepared, having completed only 100 of the 400 pediatrics UWorld questions. Gentle Greg, a soft-spoken classmate: “No one has figured out a good balance between clerkship and studying.There is just no time.”. His father is a critical care hospitalist who trained as a physician in his native India and practiced in both India and England before emigrating to the US.
A new team of residents and attending start on Monday. I introduce myself and take on two overnight admissions, both asthmatics. Our hospital has had two deaths from asthma attacks the past year. The pharmacist who joins us on morning rounds comments: “There is no excuse for kids dying from asthma. It’s a completely controllable disease. More so than even T1D [Type 1 Diabetic]. The best insulin control and medical communication can still sometimes not be enough to control hyperglycemia. The five-month-old who died from status asthmaticus is tragic but can be justified as unavoidable. There was no prior history. But that 16-year-old who died at her Subway job should have been flagged by her family and physician for using a rescue inhaler [albuterol] every few hours rather than taking her [steroid] controller medication daily as instructed.”
I take care of a 13-year-old T1D admitted for DKA [diabetic ketoacidosis]. We were taught about different types of insulin, but we were never taught practical lessons, for example, the three types of standard sugar control regimens, how to administer the insulin, how an insulin pump works. I ask my resident to go through the basics before I go into the room and make a fool of myself and the team. Most diabetics take daily or twice daily long-acting insulin (Lantus or Levemir) to act as the foundation. In addition, after every meal they do a carbohydrate correction (e.g., 1 unit for 15g carbs for lunch and 1 unit per 30g carbs for dinner). Lastly, they do a sliding-scale adjustment every 2 or 3 hours, where they administer 1 unit for every 30 mg/dL glucose above 130 mg/dL. She has been hospitalized six times in the past 2 years for DKA after relatively good glycemic control since the diagnosis at age 3. We are not exactly sure what happened. The residents suspect that, given her age, she is refusing to take insulin as prescribed as a weight loss strategy (“diabetic anorexia”).
[Editor:A friend who has managed Type 1 Diabetes since childhood wrote the following private message: “I always see people posting on Facebook how they go to CVS to buy insulin and it is $500 a bottle (lasts me a month but lasts fat people 2 weeks) and they are so mad that companies are ‘allowed’ to charge this. I ask them why they go to CVS and pay retail when the same insulin is $40 a bottle mail order from Canada, including shipping. And the older kind is $29 a bottle at Walmart. Almost no one in the UK has insulin pumps because their health system doesn’t provide them for free. Pumps are $6000 here new, but I got two for free on Facebook and you can buy them on Craigslist for $300 except do-gooders report the listings and get the listing taken down as Facebook, eBay, and Craigslist don’t allow them to be resold.”]
An 8-year-old is admitted for poor weight gain (4th percentile for weight and BMI) and acute episodes of diarrhea. We need to get his charts from an outside institution also on Epic to determine when he fell off the growth chart. In theory this should be easy with Epic’s “Care Everywhere” reconciliation. However, we spelled his last name wrong in our system, causing a failure to synchronize with the outside institution. IT informs us we that it is impossible to correct this error until after the patient is discharged.
Part of the medical student’s role is to get medical records from outside institutions. How does this work, nearly 10 years after the American Reinvestment & Recovery Act, which included the “Health Information Technology for Economic and Clinical Health (HITECH) Act” that provided taxpayer funds for computerization of medical records? The core technologies are the telephone and a FAX machine. Here are the steps:
- 20 minutes on hold
- speak to the medical record department
- get their institution-specific medical request form faxed to us
- fill out the form with help from the family, e.g., to learn the Social Security number
- fax the request form back
- wait 30 minutes for the requested documents to appear on our fax machine
This is not to say that the electronic medical record (EMR) has had no effect on the process. EMRs may automatically add vitals at 15-minute intervals to the record and therefore even the simplest data request usually results in at least 10 pages of irrelevant notes before you get to the information that is sought. I learned that it is more efficient to ask the patient to call the institution and speak with a nurse who can relay relevant labs over the phone. I then type them into our Epic system. Even triple-checking the values on a voice call, the total time and effort is much less than using EMR+fax.
I say farewell to my team and head off Wednesday afternoon for a lecture on childhood GI bleeding. The lecturer speaks in a monotone, reading verbatim off the slides of a presentation that someone else created. I ask classmates if it was obvious that I was dozing off. Anki Alex, a class gunner who does 300 Anki cards daily on rotation: “Big Dawg, every person was dozing off. There was a wave of head bobbing. The few times that I myself wasn’t sleeping it was hilarious to watch.”
We take our exam Friday morning. Crisis ensues at the exam. The hospital WIFi is intermittent so every 10 minutes the private secure browser in which we take the NBME Shelf exam shuts down. Nervous Nancy’s computer works fine and she is taking her exam while the other 25 students shriek and hollar. Exams are typically proctored by two people: a clerkship administrator and someone from IT. Today, the IT proctor is sweating and scrambling. His best theory is restarting each computer after every shutdown, but today this is providing only another 10 minutes before the next shutdown. After 30 minutes, the clerkship coordinator kicks everyone out to give Nancy some quiet. We are then called in one at a time to log on and restart the exam. This process of getting people restarted for the 2-hour, 45-minute exam takes about 2 hours.
The exam is probably the hardest exam I have taken throughout medical school.The average is low enough the passing score is rumored to be 60 percent correct. The pediatrics shelf includes questions on childhood skin lesions, upper airway versus lower airway disorders the amoxicillin drug reaction from mononucleosis, several challenging autoimmune disorders (e.g., compare Bruton-K agammaglobulinemia versus Common Variable Immunodeficiency), and an annoying nephrology biopsy image (Pinterest Penelope: “blast from Step 1 past”).
Type-A Anita complains to the administration that the disruptions affected her exam performance after we finished the exam. We got an email on Saturday:
We apologize for any added stress caused by the technology issues during testing this week. Thanks to the determination of our IT professionals, we understand now that the issue was beyond our control and that it has been resolved with the necessary groups. … Although we will not receive results from the NBME until this weekend, please understand that all contextual factors will be considered in the case of any undesirable outcomes.
Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. We grab burgers and beer with Mischievous Mary who just finished her OB rotation. “You hear the most ridiculous stories. The residents and students sit in an alcove that is obscured by walls from the patient hallways. An African-American in his late 20s came up to the nurses and said: ‘Ma’am, my wife and girlfriend are in rooms next to each other. Could we move them so they are not near each other.'” She continues: “You’ll also hear the worst baby name choices. I asked the attending if she ever tries to change their minds? The attending responded: “Only once: the patient wanted to name their daughter Chlamydia. I talked them out of that.” She concluded: “I never appreciate how obstetrics is such a surgical field. I am actually considering OB now instead of CT surgery.”Full post, including comments