The agony of the unknown

Many times in medicine, a diagnosis may not be clear from the beginning. Some things are obvious. A kid who has wheezing and hyperinflated lung fields on X-ray, probably an asthma attack. Tympanic membranes that are red and bulging with pus behind the ear drum, otitis media. But then there are the mysteries. The ones where you get a few clues here and there. Or maybe you had no idea that something was brewing all along. You thought you had the whole picture, but it turns out there were things you missed. Were there clues all along? Should you have suspected the diagnosis? So then you begin to gather evidence. You ask the parents questions about the child. This is called taking a history, and it's something you learn early in medical school. We learned a technique called OPQRST: Onset, Precipitating/Provoking factors, Quality, Radiation, Severity, and Timing. You try to fully describe the symptom and get a clear history from the person who has the complaints (or their parents). You get a family history, too. You ask questions about the family members - have THEY ever had these symptoms? Then you do a thorough physical exam, trying to focus on the things you think might be going wrong. Is it stemming from the brain? So you do a thorough neurologic exam - cranial nerves, gross motor, cerebellar function, reflexes, gait. Is it the heart? You listen for a murmur, feel the precordium, check pulses, capillary refill. You do an abdominal exam, looking for enlargement of the liver or spleen. And then you run tests. Blood tests, urine tests, maybe even check the cerebrospinal fluid. You put the patient through all kinds of painful tests, some of them including invasive procedures like liver biopsies and bone marrow biopsies. You order X-rays to look for evidence of what's causing the problem. Plain films first, then CT scans, maybe even MRI's or nuclear medicine studies. And sometimes, even after ALL of this... you STILL don't know what's going on. What is the problem and how are we going to fix it? That's the agony of the unknown. It's horrible for the person who's suffering AND for the person who's looking for answers. How do we find the answer? Will God reveal it?

You know, often I think this same logic can be applied to problems in life. Something comes up, a symptom arises to cause someone to question something they didn't know was wrong. So we seek to gather more information. We ask lots of questions, look for more evidence, run some tests, spend exorbitant amounts of time and energy trying to figure things out. It is emotionally and physically draining. In the end, we just want the answer. But God doesn't always paint the answer in the sky. Sometimes it takes faith. And that can be kind of scary. Stepping out on that ledge and trusting that God will not let you fall. And to make matters even tricker, there's an Enemy who throws obstacles in our way. This happens in medicine, too. We call it "red herrings". Sometimes we get information that makes us think it might be one diagnosis. And we may even lock on to that diagnosis. But then we realize we were totally led astray by the red herring. That's what Satan does in our lives. He throws red herrings our way. He makes us think perhaps we're not doing what God wants. He is the master manipulator, the greatest liar ever. And he hates to see God's people glorifying Him. So he will do whatever it takes to fool us. So how do we find the truth in all of this? When we've collected all the evidence, listened to everyone's opinions, considered whether some "facts" are actually red herrings... how do we come to a conclusion? The only answer I can think of is to pray. Pray, pray, and pray some more. Pray that God will reveal the truth, and He will not lead us astray. And lean on the one truth we are sure of - Christ Jesus.

That's why your mom always told you...

No running with pencils!!

We had a patient come into the PICU who had a pencil stuck in her eye.  This isn't a picture of her, but it's probably what she looked like in the ER before she went to the operating room.  She apparently was running with a pencil, tripped and fell, and rammed the pencil through her eye socket.  Amazingly enough (and miraculously for her!) the pencil just missed her globe and went right next to it through her orbital canal and into the front part of her brain, missing all of her critical eye structures.  She didn't lose any vision, her muscles weren't injured, and there was no brain bleed.  In the OR they removed the pencil and cleaned out the wound, and she was brought to the PICU with a bandage over her eye.  I think she's still on the ward for antibiotics, but overall she was an extremely lucky girl!!  When I told her she was lucky, she replied, "Yeah, I know.  And I'm even luckier because I get to go to Sea World."  Uh, managing not to lose an eye vs. Sea World??  I'd rather have my eye.  Crazy kid.

Happy stories!

It's not all sadness in the PICU, thankfully!  There are some happy stories.  I'd like to share a few.

JS was a teenage boy who had just gotten a new motorcycle and went out for a joy ride.  He was wearing a helmet, but unfortunately the front piece was not attached... and JS ran into a pole.  Yikes!!  He lost consciousness, and basically his face took the majority of the trauma.  He had multiple facial fractures, including his eye socket, jaw, and skull.  He had massive bleeding in his head, mostly in the frontal lobe (the area of your brain responsible for executive function, making decisions, social inhibition, and long-term memory).  He was aggressive at the scene, requiring sedation and intubation.  He had a number of invasive surgeries and was on the vent for a week.  We weren't sure if he would wake up when we took away the sedatives, and if he did wake up we weren't sure if he'd be the same person.  Well, a week after he came in, we turned off the sedative drips.  Within hours, JS woke up and was looking at his family and squeezing his sister's hand.  Now he's making huge leaps in recovery, already up and walking.  Amazing!

DG was another teenage boy who was hanging out with his cousin, who was cleaning his gun... which was loaded, by the way.  Next thing you know, his cousin accidentally fired the gun and shot DG in the head.  He lost consciousness and had severe intracranial bleeding.  The CT of his head looked crazy - almost his entire right side was destroyed by the bullet.  He went to the OR on his first day of hospitalization to get a decompressive craniectomy.  Basically what they did was take out part of his skull to give his brain room to swell.  He was on heavy duty meds and was on the vent for a week before he was ready to extubate.  We lightened the sedation in anticipation of pulling his breathing tube, and guess what - he woke up!  He opened his eyes, gave a thumbs up, held his dad's hand... incredible!!  He is still in the PICU, but making significant progress.  Praise God!

Finally, DE was yet another teenage boy (these crazy teenagers!!) who was out at the river having fun with his friends.  Like any fun-loving high school guy, he decided it would be fun to jump off a tree branch into the river.  The problem was, as he was getting ready to jump, the branch broke... and he fell into the river at an awkward angle, landing on his neck.  He injured his spinal cord, fracturing his C5-C7 vertebrae.  He didn't lose consciousness, but on impact had loss of sensation from the waist down.  He came into the PICU and was started on a protocol for medical management of spinal injuries.  He got IV steroids and a vasoactive medicine to keep his blood pressure high (with the idea of increasing blood flow to his spinal cord).  There was nothing surgical that could be done.  He has now been in the PICU for over a week, and is starting to have a tingling sensation in his legs.  And this morning, I swear he could tell which foot I was touching.  I'm not sure how much function he'll re-gain, but I am extremely hopeful and I've been praying for him.  The happy part in his case is that he's still here!  He could've died from that injury.  He's such a sweet kid, too.  He is taking it all in stride.

So, there are a few happy stories from the PICU after all the sadness.  Yay!

The sad part about Pediatrics

I'm working in the PICU this month.  It's at a trauma center, so we see quite a few serious injuries.  Mostly from car accidents.  But almost as frequently (or so it seems) we see children come in with injuries due to child abuse.  Last week a 12-month old baby boy came in unresponsive.  The parents reported he had been "out of it" and vomiting for a day.  They couldn't recall him falling or hitting his head, and there were no signs of trauma on exam.  There was no history of toxin ingestion.  The CT of his head showed intracranial bleeds and a very swollen brain.  What was the cause?  We weren't sure but we had our suspicions.  The next day, the eye doctor did an exam and found severe retinal hemorrhages - almost pathognomonic for child abuse.  This little boy had been shaken badly by someone, so much so that it caused bleeding in his brain and severe swelling.  His intracranial pressures got so high that he had to have emergent surgery to have part of his skull taken off so his brain could expand.

Despite these extreme measures, this patient went on to develop brain death.  His brain became so swollen that the blood flow had almost ceased completely.  Once he was declared brain dead, the parents and medical team decided to take him off life support.  His heart stopped 18 minutes later.

This is the second death I've seen this year.  The first one shook me up so badly that I cried for almost a week.  This time, I didn't shed a tear.  I don't know why.  Maybe because he came in and died so quickly.  I didn't have time to get attached.  Or maybe because I didn't actually code him.  Or maybe because I'm growing calloused?  I don't know.  I tried to say a prayer for him, but my heart wasn't in it.  I think I felt more angry than sad.  I'm not sure who abused him, but I sure hope he/she ends up in jail.  I don't understand how somebody could hurt a little child.  Children are so small and vulnerable.  They are completely dependent on adults.  They are so trusting and most of them just want to be loved.  It makes me SO angry to think of all of the children out there being abused, like my poor patient who died.  He left this world far too soon.

Anyway, that's just one of the reasons I don't think the PICU is my calling.  It can be really depressing!  Also, I don't like to have to think on my feet.  And I like my sleep.  But God bless the people who do choose to go into it.  They are definitely special people, and a blessing to all the sick children they take care of.

Pediatrician AND Ghostbuster

Last week in clinic I had possibly the strangest patient encounter ever.  I looked at my computer and it said, "7 year old with sinus pain".  I thought to myself, "This will be easy.  I'll take a look at her sinuses, maybe get a CT, maybe do antibiotics, and send her on her way."  

Not the case.  This little girl walks into my office with her parents, mom looking very concerned.  I start off by saying, "So, your daughter is here for sinus pain?"  Mom replies by saying, "No, that's not why she's here.  My daughter has been seeing ghosts."

Okay, stop.  Am I a pediatrician or a ghostbuster?

After I got over my initial shock, I began my interview.  I asked the patient to tell me about the ghosts.  She said they are black, white, all different colors; some look like people.  She sees them at home, school, everywhere.  I was a little worried to ask her if she saw them there in my office... I was afraid she'd say, "Yes, in fact there's one right next to you."  Then I asked her if the ghosts talk to her.  "No.  But they scratch me sometimes."  Mom piped in and said, "Yes, I've seen the scratches."  Then mom launched into a story about how she had gotten attacked by a ghost several years ago.  That's when I started to become skeptical.  Was this mom feeding into this child's "visions"?  Was mom psychologically in the state of mind to make medical decisions for this child?  I told her as respectfully as I could, "Ma'am, I'm sorry your daughter is seeing these frightening images, and I wish there were something I could do for you, but I'm really not trained to handle this.  I am here to rule out any MEDICAL causes for her hallucinations."  Oh, that did not go over well.  The little girl's mom started getting very heated up, exclaiming "I know my daughter is seeing ghosts.  There's nothing wrong with her medically.  She is seeing ghosts, like that little boy in The Sixth Sense.  I'm afraid they're going to start hurting her.  You have to do something to help us."  I don't know what she wanted me to do - perform an exorcism???  I calmly told her, "I'm very sorry she is so upset and scared.  I will try to find someone who is trained to help you."  That's when I called the psychiatrist.  He was very helpful and agreed to see my patient the very next week (usually not that fast).  Mom was okay with that, and after 20 minutes discussing ghosts, I said goodbye to this strange family.

It was definitely an interesting appointment, and worth writing about so I can laugh about it later.  But I do hope this girl finds some help.  She was sweet.  And who knows, maybe she IS seeing ghosts.  Yikes!!

Attitude adjustment

Lately I've been so negative.  If not out loud, then definitely in my thoughts.  I need to change my attitude.  Below are two ways I can think about my work week, negative vs. positive.

Negative:

I have been SO tired lately!  This rotation is kicking my butt.  We have to do all these stupid assignments and the cardiologists are making me drive all over the city to follow them around.  Monday I had to drive 3 HOURS each way to Ft. Hood and tomorrow I have to go to two hospitals to sit and listen to an EKG talk that I've already heard, ugh!  I have no energy, I'm tired of this rotation, and I'm tired of residency.  Maybe I shouldn't have been a doctor.

Positive:

Wow, I have really been working hard this rotation!  But I've been learning a LOT, and it will help me in the long run.  It's a tough rotation for sure, with all these tests and assignments.  But I've passed everything so far and it's a learning process, even if it is painful at times.  What a privilege that I get to work with these cardiologists, who are renowned in their field.  I get one-on-one teaching with them and I see some great cases by going to all these hospitals.  And even though I've heard the EKG talk before, I am certainly not an expert so I'm sure I'll learn something tomorrow.  Residency is tiring - I knew that going into it.  But I trust that this is where I'm meant to be, and God will give me rest and the strength I need to do this.

If only I could think positively all the time.  But it feels so unnatural and phony.  I suppose if I make a conscious effort to change my thoughts like that, then over time it will happen more and more naturally.  Well that's it for today.  Off to work!  :)

M.D. = Make Decisions

When I was a fourth year med student doing my Emergency Medicine rotation, one of the ER docs told me, "M.D. means Make Decisions."  I've always been pretty wishy-washy.  I have a hard time making decisions about the most trivial things.  Take my iPhone for example.  I spent about an hour in the AT&T store trying to decide if I wanted 8GB or 16GB, black or white (I ended up getting 16GB in black, in case you're wondering... after switching between white and black several times).  But now I'm a doctor and I'm supposed to make decisions everyday - sometimes tough or tricky decisions.  This is one of the key components of being a good doctor, and I've observed this in some of my favorite attendings.  The ability to make a decision and commit to it.

It doesn't come naturally to me (obviously, since I spend hours deciding on things like phone colors).  But every time a decision is placed in front of me as a doctor, I consciously remind myself, "Make a decision, Linda, and stick to it."

Yesterday I sent two kids to the PICU.  The first one was a 12 month old girl who had pneumonia and was working hard to breathe.  I did my assessment and decided I wasn't quite comfortable with her staying on the floor.  She's doing fine and her labs were reassuring... but she ended up on continuous nebs which is a reason to go to the PICU.  So maybe I made the right decision by chance.  Then in the middle of the night I got called for a 2 year old boy who was having difficulty breathing after being extubated (he was under general anesthesia for a small procedure).  When I got there he looked bad.  He was sucking his chest down to his spine and had a barking cough.  I told the Anesthesia guys, "Yes, he needs to go to the PICU" and together we came up with interventions for this little guy's upper airway problems.  He started looking a lot better and by the time he got to the PICU he looked 100% better.  I felt a little silly bringing a comfortable, crying baby to the PICU, but considering what he looked like when I first saw him, I felt very justified in my decision.  And I committed to it.  It was a good feeling.

I'm in a transition period now where I'm getting towards the end of my second year.  In July I will begin my third and final year of residency.  I will be expected to make decisions all the time.  I will be the senior resident on call and I'll have first and second year residents looking to me for answers.  It's a little scary, but I think I'm ready.  Or at least, I hope so.  We'll see!