Pediatrics Week 5 Babies

September 1, 2010

This week I reported to work with one hope: that there would be at least one delivery.  There were two.  The first came in the middle of patient rounds.  The beeper went off, and I was surprised by how fast the residents started running toward the door.  I rushed to catch up, losing time as I squirted alcohol cleaner on my hands.

As we walked, they told me “it’s a 9-1-1.”  I had no idea what that meant, but later learned this is the term for any delivery that was unplanned.  Usually the pediatrics team doesn’t go to full-term, vaginal deliveries.  We are called at all C-sections, premature births, or when the baby might be in distress.

This time it was a premature vaginal delivery.  We rushed into the delivery room, and I was surprised to feel the mood change immediately.  Birth is so intense, and this delivery had gone fast.  The lights were dim and yellow, like a glowing fire.  The head was already out, and seconds after we arrived, the baby was placed on the warming table.  The residents were still scrambling to turn on the oxygen and suction dials on the wall.

There in front of us was baby, covered with white cream and smears of blood.  A 6-inch umbilical cord hung from him, and looked like part of a jelly-fish.  He looked up with big, blinking eyes.  I was frozen… WOW!

The residents immediately started rubbing him, squeezing his umbilical cord to take his pulse, listening to his heart, suctioning him, and then giving oxygen with a positive-pressure mask.  I tried to do something useful, which was impossible at first.  I smiled at dad who had come to observe us.  I listened to baby, but I didn’t know what to make of his raspy lungs.   He was having some trouble with his breathing.

Every few seconds, they would count 1-2-3 and in a coordinated dance, lift baby and change the cloth underneath so he would stay dry. Finally, we clamped his cord close to his belly, and dad cut it.  Then, we bundled him, and they let me, the medical student, carry this brand new bundle to his mother.  I handed her baby, and said, “felicidades” because she and her husband spoke Spanish.

The second call came during lunch.  Again, I dropped everything and tried to keep up with the residents.  In fact, I left my stethoscope on the chair!  This birth was also a premature vaginal delivery, but it was slower.  We had plenty of time to set everything up while mom was in the final stages of labor.  I was alarmed by the tubes they prepared, in case they needed to intubate the baby.  They checked the suction, and the oxygen bag.  This time I knew what to expect, so I got ready to help with the drying, rubbing and blanket-changing dance.

These were the first births I’ve seen since my brother was born, almost 20 years ago.  I barely remembered the chaos that happened right after my brother was born, but it suddenly came back.  There was lots of rubbing and suctioning, and I cut his umbilical cord a while afterwards.  He was swaddled in a blanket, and I held him and handed him to my mom.

Most of all, I was in awe of my brother, just as felt as I watched the newborns in the nursery.  There is something so special about new babies, new life, and the moment of birth, mixed with pain and joy.  I thought I was going a little crazy after spending time in the nursery.  I started looking at baby outfits on Google.  Then, I even thought about having a baby before I finish medical school… for about 30 seconds.

The truth is that starting a family during medical training is terribly difficult, especially for women.  I’ll explore this topic in a different entry soon, but for now I am enjoying the new babies, one of my favorite parts of pediatrics.  Getting to see something so sacred as human birth and newborns makes all my sacrifices seem worth it.

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Posted by Liz

Pediatrics Weeks 2-3

August 19, 2010

This week I reached the half-way point of my pediatric rotation, which marks a switch from inpatient service to outpatient ambulatory care.  I felt reluctant about this change, since I was just starting to feel comfortable with my role with the inpatient team.  I had a good experience, besides fainting on the floor (even that turned out to be not SO bad).

My memories from the inpatient weeks revolve mostly around the people. Medical students who begin 3rd year especially remember their first patients.  It wasn’t until my second day working with the pediatrics inpatient team that I was assigned to a new admission.  I felt excited and nervous as I went to meet him.

He was a toddler “with history of CHF (Chronic Heart Failure), admitted for 2 days of worsening fever and respiratory distress.”  What I wasn’t prepared for was that mom spoke only a little English.  She understood Spanish, but spoke primarily Portuguese.  Along with an intern and the head resident, we took a history of his illness from mom, asking questions in Spanish and deciphering answers in Portuguese and English.

I was expecting him to cry when we examined him, but he was quiet and still.  I moved my stethoscope along his torso, listening to his heart, lungs and abdomen while he was quiet.  Then, I examined his ears, eyes, head and throat.  We determined he probably had a viral infection, most likely to be “RSV” (Respiratory Syncitial Virus).  This case was “bread and butter” (common) for pediatrics.  In fact, there was not much we could do for him besides monitor his respiratory and cardiovascular status and treat his symptoms.

I wanted to do more.  I came home and read journal articles on RSV treatments.  Asthma medications weren’t recommended because the respiratory obstruction was due to mucus, not inflamed airways.  Saline nebulizers could be used to reduce the mucus, but the evidence was still “inconclusive.”  Heliox (helium and oxygen) was useful in extreme cases, but it is extremely expensive.  There weren’t any easy solutions, and this is the case with many patients.

As the week went on, his story blended with others.  Coincidentally my second patient was another boy with a probable RSV infection and a history of heart problems.  This time I learned about WPW (Wolff-Parkinson-White Syndrome), a type of “SVT,” (Supraventricular Tachycardia), especially common in children.

As the days passed, my patients’ diagnoses broadened to include asthma, cellulitis, dacryocystocele and febrile seizures.  During rounds, I heard the stories of other patients: dermatitis herpeticus, functional constipation with encopresis, bilious vomiting, bloody diarrhea, accidentally cut gastric-tube, fever of unknown origin, mysterious ALTE’s (Apparent Life Threatening Events), and a child who had been in a mysterious coma for a month.

Everyday we discussed the “assessment and plan,” how we would care for each patient.  I felt my medical knowledge, the roughly piled structure of facts, start to form itself into something more concrete.  It was like I had been studying another language, and suddenly I was in the country, surrounded by people who spoke only that language.  I was overwhelmed, clueless at times.  I started scribbling words that I heard often, like: MRCP, VCUG, KUB, NCAT.  The everyday language was different from what I had studied.

From my first patient to my second, third and fourth, I already started to feel a huge difference.  I learned the order of notes and presentations.  I used some of those previously foreign acronyms myself, and I entered patients’ rooms with more joy and less trepidation.  My performance has been far from perfect, but these first patient memories are the best learning experiences in medicine that I have had so far.

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Posted by Liz

Physical Diagnosis

April 26, 2010

6 weeks until my Board Exam!  Between studying and family visitors, this week has been fun and busy.  Wednesday will be my last weekly Physical Diagnosis class at the hospital, and I want to commemorate the occasion by describing this experience, which has been the highlight of my semester.

For the past 14 weeks, each Wednesday I have gotten up at 5:15am to commute to school, then ride a bus 1.5 hours west, and spend a day at a large regional hospital to learn Physical Diagnosis skills.  I travelled with 17 other students to participate in interactive lectures, and practice history and exam skills with in-patients at the hospital.  The day was organized so we had one hour of lecture, two hours with a patient for a complete history and exam, lunch with another lecturer, and then time to present our patient to a physician and revisit the patient.  Each week we were expected to write a complete report and submit it by e-mail for feedback.

I was worried about being exhausted (waking up at 5:15am  and commuting 1.5 hours each way), but every Wednesday I’ve felt so excited.  Rather than our typical medical lectures, which are focused around organs, these lectures were organized around symptoms, such as “dizziness” and “fever.”  My classmates and I were challenged by real patient cases, including one memorable autobiographical story that our favorite physician lecturer shared to introduce the topic of “headaches.”  He told a dramatic story about driving to work at the hospital, going 70 mph on the highway, when suddenly he felt a “pop” and experienced the worst headache of his life.  He instantly knew the diagnosis, which he described as “the most awesome diagnosis I ever made in my life.”

Any thoughts?  That’s how each day began, brainstorming, guessing and creating what is called a “differential diagnosis.”  We were encouraged to separate the “common” and “lethal” causes.  Along the way, we also learned about physical exam tests, such as the Dix-Hallpike maneuver (an exam to diagnose benign positional vertigo, a type of dizziness).  We also sharpened exam skills that we already covered, such as the eye exam.

Most importantly, we had a lot of time devoted to each patient.  I introduced myself, taking care to clarify that I am a second year medical student practicing my physical exam skills.  I saw patients from 6-months to 86 years-old, in Spanish and English, and suffering from a variety of ailments: a 22 year-old with septic bacteremia (from an infected pimple), a pregnant woman who had been vomiting blood for 2 weeks, a homeless man who had been admitted 22 times in the past year, a diabetic man who confessed he ate a Big Mac and large fries daily, and multiple chronic smokers who had not stopped smoking despite severe COPD (lung damage resulting in less ability for oxygen intake).

Often I felt overcome by gratitude for these patients who were willing to share stories, and let a fledgling examine them.  Although I came to medicine because I wanted to serve people, I usually feel that people are serving me.  I can only hope that by compassionate attention and listening, I provided some sort of healing service that complimented their care.  However, at times I wasn’t sure of this, especially when I was told to wake up patients who seemed exhausted.

I wish there were some way to thank these patients, and convey how much it means to have these experiences.  Each new patient who I meet with a certain condition becomes forever engraved in my mind with that illness.  They give me a face and meaning, and help the massive amounts of information begin to stick to something more substantial than a pneumonic or acronym.

No doubt this class was my favorite, and also the most valuable learning experience in medical school so far.  There were many visible improvements, such as increasing comfort while performing exams and asking questions, less pauses during my oral presentations and less time to type my reports.  This weekly experience will soon be my daily experience as I start my 3rd year in a few months, and frankly I cannot wait.

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Posted by Liz

ALS: Tim’s Disease

January 12, 2010

This week I learned that a college classmate was recently diagnosed with ALS or Lou Gehrig’s disease. I was shocked because he is only 30. I never knew ALS could affect people my age, but apparently he has a genetically-linked variant that has something to do with a mutated superoxide dismutase 1 enzyme. The human body is so complex, there are endless possibilities for disease, but the rare variations never cease to jolt me.

Along with the initial shock, I thought “Why Tim?” He is such a lovable and wonderful person– a musician who plays in a band. At least two close friends of mine (and probably more like half the girls on campus) had HUGE crushes on him. Now he’s newly married to a wonderful woman who is committed to staying with him throughout his illness. I didn’t know him too deeply myself, but he stood out in many positive ways. He even has a tattoo from a Quaker song book. I would never have imagined that he would be struggling with a degenerative illness so soon.

While I was in the Dominican Republic last summer (and actually had time for personal reading) I read Tuesdays With Morrie.  This is a poignant book written about a Brandeis professor who is dying from ALS. I highly recommend it. I learned that one of the doctors who was volunteering with me had a father who died from ALS too. His dad was diagnosed with ALS right before he took his Step 1 Board exam in medical school (awful timing for a future doctor).

I learned about ALS in my neurology class this fall- I learned the medical facts, that is. It sounded like one of the worst neurological diseases, not simply because it is currently a death sentence. Mainly it is terrible because a person’s body changes without the mind. In other words, ALS (like Huntington’s Disease, “Locked-In” Syndrome, or spinal injury) causes loss of body function while the mind stays completely intact.

Of course, exceptional people who are surrounded by love have an amazing capacity to cope with mental and physical suffering that disease brings. The dry facts about any disease can’t come near to the more complete knowledge of a person with the disease. They can’t begin to explain how people feel or cope.

One of my greatest life lessons of the past 10 years has been accepting mortality and tragedy.  Understanding the reality of so many bad things that can happen at any moment makes me feel scared and vulnerable.  Yet, it helps me to challenge myself, and avoid making many decisions based on unrecognized fear.  Perhaps one of the greatest lessons in medicine is not only accepting the diseases, but actually knowing the people who have them too. This next life lesson is why I am so excited about beginning my clinical rotations this Wednesday.

After this week ALS will not be just “ALS” anymore. ALS will be Tim’s disease. I won’t forget it because I can see him alongside his wife. If I see anybody with unexplained neurological weakness, ALS will be whispering in my ear and begging to see a neurologist. Thanks to Tim’s friends and modern technology, I’ll remember his experience on video, and most importantly, his story will live with me forever.

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Posted by Liz

Glioblastoma: Bill’s Death

June 18, 2009

Summer has begun, and I just returned from one of the best vacations of my life- an 18-day trip with my husband to Europe to visit my Italian family and sight-see.  I’m not sure if the trip felt so amazing simply because I have greater appreciation after working so hard, or whether it was truly just a fantastic trip.  Nevertheless I feel extremely grateful for the wonderful memories and time to travel.  Yet as I was having a great time, something striking happened back home- a deeply loved member from my Quaker Meeting died.

Thanks to modern technology, I learned of his death within three hours.  Although he was younger than my own father with two children in their early 20′s and a devoted wife, his death was not a surprise to me.  The shock began in January when he suddenly began to feel forgetful.  Worried about early-onset alzeimer’s disease, he went to his doctor immediately.  After an MRI and biopsy he was diagnosed with glioblastoma, a cancer of the glial cells that was located between the two hemispheres in his brain.

I knew glioblastoma because it was responsible for the death of two of my grandfather’s sisters- including my Aunt Dot’s death last year.  She was diagnosed in May, and she died the first week of December.  She was in her 80′s, but it was nevertheless a great shock to her children and husband, who were still depending on her for a lot of care and help with grandchildren.  The family sent updates often, and therefore I felt included as Aunt Dot quickly became consumed by the cancer.

Like my Aunt Dot, Bill was deeply loved.  He was such a talented person who had a true gift with relationships and words.  I can still hear his gentle, but powerful voice, and his laugh.  Logically, I knew what glioblastoma meant when I heard of the diagnosis- it is a death sentence.  Yet, I also knew intuitively that nobody should give up hope completely.  Being a medical student means I have access to a library of medical journals and books worth thousands of dollars, so I decided to use some of my resources to learn more about this cancer.  To my horror, the statistics were more grim than I thought.  To date not a single person with the advanced stage of glioblastoma has lived over 2 years.  The only therapy- chemo treatments and radiation- could prolong life an average of a few months.  As I read those words, I sat mortified as my hope for Bill diminished.

The shock hit me then, and over the past six months it has come and gone.  During a lecture on “Death and Dying” I thought of Bill and his family.  At Meeting, the children asked, “Is Bill dying?”  And in our community we realized that everybody is dying.  Bill and his family ever-so-gracefully were showing us the tragic truth that life will end, and nobody can control their death.  Medicine acts like it can save people, but it usually cannot.  We often tell ourselves that death will come tomorrow, but it could come today.   And as I mourn for Bill and rejoice in his life, I feel humbled.

I am preparing to leave for my volunteer service in the Dominican Republic, and one question that has been on my mind is whether we can truly help those people with severe or chronic medical problems in our rustic general-medicine clinic.  I realize, however, that my rural village has probably lost many people like Bill.  Since they are a small close-knit community, no doubt they have already accepted the truth about death.  In a community that rarely gets any medical attention, people have probably learned to cope with unexpected and inexplicable death and suffering much better than the average American.  This is something that I’m still learning- something that Bill, my cadaver, and others have helped me see- that sometime we must suffer, and sometime we will die, and there is nothing anybody can do to prevent it.

“When you were born, you cried, and the world rejoiced. Live your life in such a manner that when you die, the world cries and you rejoice.” – an Indian proverb

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Posted by Liz

My First Patient

August 18, 2008

Sometimes when I am really bored with memorizing basic scientific facts, I think about Viktoria.  She is one reason why I want to learn medical knowledge- because she needed help to solve her painful mysteries, and I wasn’t able to solve it myself.  Her black and white scans looked like abstract paintings, and even after the doctor named her condition, I felt clueless.  I think of her story, and I feel motivation to learn more…

I will always consider Viktoria to be my first patient.  Her mother Dana came to me in tears (which was unusual because Ukrainian women rarely cried, especially in front of strangers).  She explained the situation.  Her daughter was 8-years-old, and over the past two years had developed a knot in her upper spine.  She was in chronic pain, and slowly losing movement in her arm.  She couldn’t afford to pay for care, but the doctors in Lviv had suggested she contact a hospital in Warsaw, Poland where she might receive free care since Viktoria was a young child.

Dana made a great effort to obtain the proper visas to take Viktoria to the hospital there, and the Warsaw clinic agreed to perform an MRI free of charge.  The results clearly showed a tumor, however language barriers and time limitations prevented further discussion with the Warsaw doctors. When they returned to Lviv, the doctors explained that they were afraid to operate because they could not tell if the tumor was cancerous, and if it was, it could metastasize quickly and be fatal.  Additionally, the location of the tumor, between C3-C4, was near the brain stem and the doctors felt it was too risky for their facilities.

Dana did not know what to do next.  She had been agonizing over her daughter’s condition constantly, and was not able to receive any response from the Lviv Red Cross.  After hearing her story, I met Viktoria.  She seemed to be a healthy 8-year-old who hid under a baseball cap.  She was blonde with freckles, and practiced a couple English phrases she knew.  She drew me a beautiful picture of a princess.

I was compelled to try to help her even though I didn’t understand anything about her situation myself.  Dana provided me with her MRI scans, and I spent a lot of time on my town’s slow internet connection trying to find information about spinal tumors.  I e-mailed an organization which assists American children with spinal tumors, and eventually found the e-mail address for a specialist from John  Hopkins.  I didn’t think anybody would respond to my e-mails, but they responded almost instantly.  The specialist wanted to see the MRI images.  The director of the organization wrote a heartfelt message that I later translated out-loud for Viktoria’s mother.  She cried again.

Over the course of many months to follow many events occurred.  First, upon receipt of the MRI images, the US doctor quickly affirmed that Viktoria’s tumor was “Osteoid Osteoma” (a rare bone growth that is not cancerous).  The location made the surgery tricky, but he was confident that it did not require great expertise.  With the help of Ukrainian Peace Corps doctors, I was able to locate a clinic in western Ukraine that would perform the surgery, and I gave the information to Dana.  I am still not sure how she collected funds for the operation, but Viktoria finally had the surgery in April 2007, after I was already living in Boston.

I have kept in touch with her family, and she seems to be doing well, although recently Dana was concerned because Viktoria’s recent MRI seemed to show another growth (at least that is what the doctor had warned).  Again I e-mailed the specialist from John Hopkins, and again he promptly responded by telling us that the MRI was not  good quality, so it did not show anything clearly and ought to be repeated .  Knowing the complications of obtaining an MRI, I doubt it will be possible for Viktoria to get another MRI soon.  However, I assured her mother that it did not show the tumor was growing back, and the fact that Viktoria is pain-free is a great sign of improvement.

I wonder what would have happened to this young girl if Dana and I had never met.  Would Viktoria still be in pain?  I think of all those people in the world who have chronic diseases and nobody to provide them with clear answers and care.  In Ukraine (and in many places) there are countless people who cannot get care- who die of cancer without ever knowing what was wrong with them.  What a huge difference it made to have people offer free scans, explanations, and eventually surgical expertise.  For Viktoria, it was the difference of a slow, painful disability, and a normal life.

After following Viktoria, another father came to me to talk about his deaf daughter, Alina, who now has Cochlear implants.  She is the first girl in Sokal to have them, and he writes me descriptive letters overjoyed at the number of words she knows.  Modern medicine is miraculous- the deaf can hear, and the suffering are healed.  And when they cannot be, even the understanding of disease (insightful communication and compassion from others) can relieve grief and suffering.  In the course of a lifetime, we all will experience suffering and death.  But, Viktoria was an inspiration to me that least everybody should be able to understand their condition and avoid unnecessary additional suffering.

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Posted by Liz