Cold Winter's Night

Yikes, it is freezing out.

 

It's actually felt like a cold Dublin day today. Had that grey hanging cloud cover that never left, a bone-chilling cold, and some mist in the air. It was really, really slow so I actually left at about 5pm. (We're on-call tonight). There were 4 SHOs on, now that one of the others is back from vacation. So not much to do. We'd only had 4 admission by the time I left..

 

Anyway, we're rounding at 6:30 AM on the old patients (SIX THIRTY AM) and then 7:30 on the admissions from call. This seems a bit cruel, but it means we'll get out earlier tomorrow.

 

I'm going to pour another glass of wine and read a bit more of Eat, Pray, Love. Which, I must add, is turning out to be a fantastic book. Let me add one last thing. Today it dawned on my that I paid 148 ZAR for the paperback version of this book. At about 7 Rand to the dollar, it works out to be a bit ridiculous for the price of a paperback. I'll add, that the reason to read more was to find something to occupy me so I wouldn't be wasting so much money elsewhere.. Hmmm. I may have to search for a used book store, or one of those places where you go and get books and then give them back.. What're they called again? Libraries?

 

g'night

EBM is bullshit, part 2

I've called this EBM is bullshit part 2, because I've lamented both personally and via email to many about how much I have come to hate EBM. Evidence-Based Medicine.

 

I find it tedious when rounding back home to discuss which drug, if used in 1.5 billion people is likely to save an additional 3 lives, and was the study well designed, blah blah blah. Let me puke. This doesn't mean I don't practice EBM. I want to be a good doc, so I'll look up the most recent study to see which drug/treatment/witch-doctor potion is best for "X" condition. But I'll also adapt a herd mentality, and do what my colleagues do, and more importantly, what the insurance will pay for... (No use prescribing a novel drug is it cost too much for people to afford).

 

There is nothing sexy about the mental masturbation of EBM... There isn't really much sex in medicine, contrary to what the TV shows portray. What is sexy though, is when on rounds, the pathophysiology of a condition is explained, when parallels are drawn to other diseases, then the lab results etc are correlated with what's happening at a cellular/tissue level. We're talking medicine in a bikini or thong sexy here. (Aside: Medicine seems to have a lower population of people who would look great in a bikini or thong. There's some irony to that).

 

I have visions of rounding back in the US were we all pull out our tools (palm pilots!), somebody gets on-line and we debate if 1 or 2 mg/kilogram of prednisone is best for the treatment of a pedi asthma exacerbation (who fucking cares cause the kid will likely spit out part of it, part of it will spill when the jar is opened, and it'll be forgotten on 2 days)...

 

Rounding here, there's no debate on this crap, there's discussion of why thy kid with nephrotic syndrome has an elevated ESR... (GROAN-what's the evidence behind the usefulness of ESR in the diagnosis of Nephrotic Syndrome-I can HEAR that question being asked by EBM Fans)... There's a 20 minute discussion of using the history to help figure out if an infant with jaundice has a pre-hepatic, intra-hepatic, or post-hepatic problem, and a conversation of what on the clinical exam will rule-in, or rule-out which congenital infection!

 

Don't get me totally wrong, I am fully aware of the utility of EBM in advancing medicine, but sometimes I just have to think that it's at the expense of the sexy part of medicine...

3 Deaths.

This morning as I made a run for coffee, I saw the Cuban surgeon who evaluated the child who I thought may have had intussusception. And I asked him about how's the child was doing.

Dead.

Sadly, he did prove to have an intussusception, and in to the operating room, they found dead bowel. The child made it to the ICU, but they were unable to maintain a blood pressure for long. This is the third child to die, or we seem to be averaging about one a call.

I also realized that the child who was in liver failure from suspected Reye's syndrome, had also died.

A couple of days ago, I overheard they few of the pediatric residents talking about the number of deaths from last month, and I don't recall the exact number, but I do recall one of the residents saying "well, you're under 10%." As if 10% were of the upper limits of acceptability. And I hope to point out that this reflects not only to the limitations of services, but also the severity of illness that is seen at the hospital. I highly doubt that the child with intussusception would have survived back home, and he came to the hospital so late.

On Fridays, the head Professor of the pediatric department rounds with the team that is on call on Saturday. Which means that the prof rounded with us today. We made a run through the ward and reviewed some of the unique admissions. It was phenomenal teaching. I was slightly apprehensive that this was going to be another pimping session, and was afraid of coming up with blank answers, but instead it was more of a guided tutorial at the bedside. This is how teaching should be. So we rounded on about six or seven patients with the prof, and there was much to discuss. The depth of knowledge of the prof was fairly impressive.

I diuresed my patient list today.... both Baby S and baby T. were discharged. Fingers crossed, and that we continue to get some adequate nutrition and gain weight. Baby T. is moving out of the area, and I am actually a little afraid that his mom won't follow through on getting him care for his HIV status.

As for follow up, our boy to was admitted with bilharzia continues to have bloody urine, and has failed his first treatment course of which apparently is not usual.

A, my 2 1/2 year old who has right-sided heart failure from an obstructed airway... I spoke to the ENT doctor today and explained the story, and apparently they will see the child in clinic on Monday. He was at least interested in seeing the kid, and his initial thought was that he will have to schedule the child to have his tonsils and adenoids removed.

And the and shocker this morning was going through results and finding out that baby M is actually HIV negative. He is the child who is six months old and has failed to meet most of his developmental milestones, and came in with failure to thrive. It was assumed that his neurological status was due to his HIV disease. His mom was tested on admission, and she tested positive so he preliminarily was considered positive as well based on his clinical picture. (He had other stigmata of HIV disease). Ironically, when I admitted him, his hypertonia and overall condition let me to think that he probably had cerebral palsy. And now that he has ruled out for HIV with a negative PCR, he probably does have cerebral palsy. Thankfully, the occupational and physical and speech therapists have had time to work with the mom and have made a little bit of progress, as well as to get him set up for outpatient care.

.

Registered

 

Finally.

 

After uncounted unanswered emails and phone calls, lost and then found and then lost and then found and then lost and found again money, I am registered to practice medicine here in SA.

 

Now I feel like I legitimately belong here. Tomorrow I can start enhancing my skills at IVs and blood draws. I spent 4 hours in Pretoria today getting this finally settled, so was only in the hospital for a few hours this am...

 

 

In Another World

It started off as one of those days... We're post-intake (call) and so I got to work early so I could round on my old patients, before we did the post-call round and saw all of the new patients.

There were 25 admissions yesterday.

 

Kiddo A: my 2 and a half year old who has cor pulmonale (heart failure from a non-cardiac cause) has gotten better w/ diuresis, but it is now PAINFULLY obvious that the problem is that the kid needs his tonsils and adenoids out. The cardiologists signed off after they did their echo. Apparently the kid needs a neck xray before the ENT docs will see him. And I fucked up and wrote his name on the wrong list so it didn't get done yesterday!! Argh, wasn't too thrilled to figure that one out this am. Hospital day # 10 for this kid. So, he finally got the xray this am, and I asked about getting the ENT docs consulted. To which I hear I need to get the radiologist to read the xray. Well, at 3pm when all the other urgent stuff has been done, I enquire about getting the xray read, to find out that it has to be read earlier in the day, that they are gone by this time. And, then my coworker guestimates that it could be months before he goes to surgery...

 

Kiddo K: Day of life #70, born with transposition of the great vessels, with NO shunt who was admitted with sats in the 30s (who knew that was compatible with life), and eventually had an atrial septostomy, and I've been caring for him for almost a week now. We're waiting to make sure the kid gains some weight and to get the cardiologists final blessings before sending him back to his home hospital. Yesterday, we tried a trial off oxygen. He failed. Back to a sat of 30. (his goal is >70). So back on oxygen he went. This am, the oxygen mask is (no nasal prongs his size) hanging close to his air passages, and sats are 60...  

 

Kiddo K: a cool 3.5 y/o who has some congenital renal/bladder issues (history of posterior urethral valves) who has been in the hospital for a week. Reasons not worth going into. Who I couldn't FIND this am. Don't get me wrong, this happens back home often w/ medicine patients, but not w/ kids. He'd been in isolation on another ward, but we were taking care of him, and he was due to be transferred back to our ward... So, after walking between the wards twice, and looking for the familiar face (and he's a cutie!), I gave up and decided to ask the nursing staff... but, and this is a great part of the day: It was the time of the day where the nurses start their shift with singing. There is no interrupting the am ritual of morning song, and no interrupting morning report (which lasts for an hour). I figure that at some point, the kid will appear (I don't even think the kid should be in the hospital, and I make a mental note to see him before I leave).

 

So, needless to say, it was a bit frustrating this morning.

 

But,  there were some really good things about this morning as well. Some of the kids that I have been taking care of for the past week are starting to look much better. Baby S and baby T are both starting to put on a little bit of weight, and are even starting to show a bit of personality. They look much different than when they were admitted a week ago. Instead of examining them from head to toe each morning and a looking for new problems, instead I enjoy picking them up and examining them while I carry them around. In some ways, it feels like a leap of faith to let them leave the ward, which will hopefully happen in a few days.

 

We eventually got around to starting our post-intake ward around, and again, we hit almost every chapter of a peds  textbook (there was no cardiology stuff today). Some notes I made during rounds.

 

1-We're taking care of an infant who is in acute liver failure. The reason is not entirely clear. The best working etiology is that we are seeing another possible case of Reye's Syndrome. There was debate on the ward round as to whether this kid was a candidate for intubation and for the intensive care unit. After some lengthy debate, the child was intubated after discussing w/ the ICU if there would be room for him.

 

2-We admitted two children with diabetic ketoacidosis, both are new onset. It was oddly refreshing to see a medical condition which I feel fairly comfortable with. However, I realized that my usual management was a bit different. Whereas, one of the new onset kids was in mild DKA, and could have been managed with subcutaneous insulin, both were managed with IV insulin coverage. I was also curious to see what kind of insulin regimen these children would to go out on. It looks like we will be covered on three times daily regular insulin and then intermediate insulin at 10 p.m.

 

3-We had another organic phosphate poisoning. We seem to be averaging about one on each call.

 

4-I admitted a three-month old who has been jaundiced since birth. This is the first admission for this condition for this child. I can't quite piece together all the details, but apparently when the child went for immunizations yesterday, the general practitioner noticed the jaundiced and referred the child to us. I am not sure how the jaundice was not noticed during the previous immunization visits. The working diagnosis is some form of biliary atresia. However, just before leaving, the CMV came back w/ positive IgG and IgM... perhaps this is fallout from congenital CMV?? I need to read up on that tonight.

 

5-Mumps: We admitted a child with mumps as well last night. However this is not just simple mumps. This child also has bilateral ear infections, is malnourished, and likely has HIV +/- TB.

 

6-Congenital Myopathy?? We rounded on a new three-month old who is admitted for hypotonia. We're talking flaccid like a rag doll. And she's been this way since birth.

 

7-Pneumococcal pneumonia...

 

8-Hep A: were seeing a three-year-old who was diagnosed with hepatitis A a few weeks ago. However she is having worsening jaundiced and appears to be going into liver failure.

 

So, it is quite a busy service....

 

I kept a list of things to read up on tonight, but it is too extensive to hit all the topics.

 

 

Intake

We were on intake (aka call) Friday night. Basically 24 hour admissions, and it was a light call with only 16 admission or so. The process goes something like this: Kids with medical problems are seen in POPD (Pedi Outpatient Department-AKA pedi ER) unless they are a trauma, in which case they are seen in the trauma unit (flashbacks to 2003). They docs in POPD do their stuff, and it seems like kids can be there for a while.. initial hydration attempts, maybe x-rays (not usually labs). If it looks like they are going to need admission, they are shipped over to the Admission Ward (Ward 36). This to me is brilliant!

 

Once we'd finished most of the days chores, the team essentially splits up. Some in our ward, and then the others headed to the admission ward. The ward is half admission, and half "High Care" Like a step down Pedi ICU. Though, that being said kids in high care may be vented, and waiting to get in the combined adult-pedi ICU. Admissions are split up, histories taken, x-rays done, labs done, etc etc etc. 

 

[reflections back home: I've often thought this is how our medicine service should be run. If they obviously looks sick, and are stable, the IM residents should do the bulk of the work up and initial management. ED decisions seem to often function at the brain stem level, not the cortical level. Sick lefts just pick 2 random antibiotics and give them, who cares about cultures before abx etc.. I digress]

 

Random pts from intake (not mine, but since admissions are a team sport you basically see all the kids).

 

An 8 month old sent in for question of gastro. The strikingly obvious thing was that his belly was HUGELY distended. You could almost make out the loops of bowel pressing on the skin. Shit, this is not gastro... Someone asks-Ileus? Maybe. We're doing IVs and blood on the kid, and he doesn't even flinch. The red flags are literally dropping from the ceiling that there is something really, really wrong here. I'm having a slight bit of anxiety at this stage cause I'm banking that this kid has intussusception! (Some know my intussusception stories from back home, so I always hesitate to bring up the I-word). This kid is not an ileus, he's gotta be full on obstruction. We get the abd x-ray, sure enough huge fluid levels, totally obstructed. Incidentally, the kid did have a CXR in POPD, which we saw after the abd x-ray, and even on the CXR you could see fluid levels. Pedi Surgeon (super guy from Cuba) comes over, he's pretty sure it's intussusception, and likely bowel necrosis by this point, and is going to get an  ultrasound. Now, even during normal business hours, getting an urgent ultrasound is a bit of a challenge... All I know is the kid went to surgery for likely intussusception. No idea how he did.

 

4 month old comes in with a sat in the 70s.... Blue. Supplemental oxygen and admit to the ward.

 

11 y/o boy admitted with Bilharzia. (Google or wiki it). Bilharzia! Looked at his urine under the microscope and boom-diagnosis made. That's good stuff.

 

I like the team sport feel to admissions. Nice to have everybody there, a procedure room-do bloods, lumbar puncture (spinal tap), and IV in one swoop.

 

When the kids are transferred to the ward. The sisters (nurses) wait until there are 3 or 4 who are ready to go, and regardless of the age they are placed on one of the famous red gurneys and covered with a blanket. A strap is placed across them to keep them from rolling off. I saw 3 infants and an 8 yr old on the same gurney.

 

Compare...

Two babies. Infants really, but they are so tiny I think of them am newborns. I've been taking care of them all week.

 

Baby S. Is 8 months old. He weighs 5 kilograms (11 Lbs). Pathetic is the word that best describes him.  He came in with vomiting, diarrhea, having been given some muti (spelling?)- or traditional meds. He is the definition of a marasmic kwash. He is wasted in size, and also edematous. He has strep viridians growing in his blood culture, and e coli in his urine culture. His lips are cracked and peeling, his perineum (the part that sits in a bike seat) is also excoriated, and raw. It's painful to look at. He usually stares off into space. He makes an attempts at a cry when examined. Again, he is 8 months old. He doesn't sit up. He doesn't roll over.  His mom is HIV +.

 

Baby T is 4 months old. He weighs 5 kilograms (11 Lbs). He came in with one week of gastro (vomiting, diarrhea). He was acidotic and ill appearing on admission, required aggressive fluids. He doesn't have anything growing in his cultures. He isn't marasmic, or kwashiorkor. His mom is HIV +

 

Baby S should weight 8 kg/17 lbs

Baby T should weight 6.5 kg/15 lbs

 

Both have gotten better as the week has gone on, both are off of IV fluids, taking in formula, and even have gained some weights. Both have been tested for HIV. It's been tough to think of HIV status as another label for all of these kids. I sometimes just think that all of the kids are HIV positive, they look so small and sick, it's hard for me to grasp that this can be the sole result of not getting enough nutrition.

 

Enough nutrition. This hasn't really been a problem in my training thus far. And, in fact, we deal with TOO much nutrition. We have a "chunky" baby who looks like a normal baby to me. But this kid looks chunky here. The other day as we were doing bloods and IVs, I tried to explain how we have to counsel parents on LIMITING junk food, eating veggies etc.

 

So there are all these new factors to deal with. HIV status. Nutrition status. I've been trying to link HIV status with overall appearance. Like, if an infant has TB, then that kid must have HIV as well??

 

And this week I learned that you can't tell.

 

Baby S is HIV negative.

Baby T is HIV positive.

 

The only way to tell is to test.