I’m back on a pediatric service, working the floors. It’s been about two years since I’ve seen a general peds floor, so I’m a bit out of practice and feeling a bit slow on the uptake. Do I know my developmental milestones? No, not really. Am I hip to the workup for precocious puberty? No. On the other hand, I see sick kids in the E/D all the time, so it’s not like I’m in an altogether foreign land.
It’s a change of pace from ob/gyn, but you've got to admit the progression is kinda elegant.
The practice of Pediatrics itself can be a bizarre way to spend your days. It’s this weird blend of medicine and . . . er - veterinary science. I picture veterinarians spending their days asking the same sort of questions I do, with exchanges that go something like this:
“So what is it that makes you bring Fluffy into the office today?”
“Well you see, she hasn’t been acting herself since Thursday, and I’m at my wit’s end.”
“I see. Is she having diarrhea? Puking? Not eating terribly well?
“Well, you know - a little of this, a bit of that. She’s just not acting normal. You know how it is doc; I can’t really put my finger on it. I think she might be pawing at her ear a bit more than usual though . . .”
Then of course there’s the physical exam. It’s not such a big deal with a cooperative ten year-old, but a screaming four year-old can be quite an adventure. One of my students cornered me the other day with, “You said he’s wheezing.”
“Damned straight.”
“How can you tell?”
I looked back at her blankly. “What do you mean? He sounds like a broken vacuum cleaner.”
“He was screaming at the top of his lungs the entire time and trying to rip the stethoscope out of your ears. How do you know he was wheezing?”
“Oh.” I had to think about it. “You’re not going to like this,” I told her, “’cause it’s sort of a bullshit answer, but I swear it’s true.”
She waited.
“You just get so you can hear it after a while, screams and all.”
She looked skeptical.
“No, honest - you do. Look: I thought my residents were giving me a line of crap when I asked them the same question a couple of years back, but after you listen to enough normal screaming kids, you get so you can tell when the screaming kid is wheezing.”
I still don’t think she believes me.
Service the past couple of weeks has been mostly variations on a theme. We’ve got little kids with rotavirus, which causes debilitating diarrhea, and little kids with RSV, the respiratory syncitial virus. They poop or they wheeze, but either way they can end up pretty damned sick. It makes things relatively easy for me (albeit rather dull) but it’s an absolute nightmare for my students. The part that sucks for the studs is that they don’t get to see much of the range of pathology for which kids get admitted for inpatient management.
The part that really sucks for my studs is that admissions which are fairly easy for me means that I have time to pimp their asses blind.
“Hey Sherri - what’s Augmentin?”
Another student pipes up, “Amoxacillin and clavulonate.”
“Oh, brilliant. Is your name Sherri?”
“C’mon - she went to Pharmacy school as an undergrad.”
“Shit. I forgot.”
I did the same thing with my other student - asked him some banal question about facial films, completely forgetting that he’s in the oral & maxillofacial surgery residency, which means that he already has his DMD. Ouch.
Few days ago was sitting outside the main entrance to the E/D in front of the security shack, reveling in the unseasonable warm seventy degree day and sunshine, reading through a landmark review article on evaluation of the child aged zero to thirty-six months with fever. Unlikely though it may seem, the paper had me riveted. The wind gusts must have been up to thirty or forty miles per hour - it was enough that our busy helicopter service was grounded - enough to make it a real pain in the ass to light a cigarette.
Pager went off and I folded the article back into my pocket and went into the department to answer it. Dr. B, my boss, was on the other end of the page. “We’ve got an admission.”
“Excellent. What’s the hit?” Dr. B. is, in my humble opinion, the pediatrician’s Pediatrician. As best I can determine, he knows everything. No matter how routine the admission, he extracts every last bit of teaching out of it, unfailingly making rounds salient and informative. I have yet to see even the slightest trace of malignancy about him, which just makes things all the better. I suspect that my seemingly carefree cynicism confuses him a bit, but he copes admirably.
“She’s a little girl with a parietal skull fracture.”
“Aw, hell.”
“We’ll need skeletal survey, opthomology consult and an MRI.”
“Yep, yep, okay . . . waitaminnit - what are they looking for with the MRI?”
“Probably a subdural or maybe DAI.”
“Yeah, but it’s not the right study for bleeding or to define a fracture. You want a CT for that.”
“Well, that’s what the private attending wants, and evidently she was in consultation with the neurologist.”
“Huh. Do you mind if I call ’em up and ask what they were thinking?”
“Uh, no. Go ahead.”
Thus began the first part of the adventure. I had to talk to three different attendings to get an answer, none of whom were terribly happy to be hearing from me. The final one in the chain was actively pissed off.
“I just explained all of this to Dr. B. on the phone. I don’t have time for this. Did he tell you to call me?”
“No. Look, I don’t want the entire story all over again, I just want to know why you want an MRI instead of a CT. Is DAI your only concern?”
“Oh. Oh yes, that’s a good question. In this case the subdural, if large enough to be clinically significant, will show on the MRI. I want to make sure there aren’t any other problems, like the DAI you mentioned.”
“Thank you, sir. I appreciate your time,” I said politely and hung up the phone. “Bastard!” I announced to no-one in particular as I grabbed my coat to head upstairs where the patient was waiting.
She was something like ten months old, contentedly cooing at her mother. Mom looked fairly concerned, and was very well dressed. Nothing flashy, just excellently tailored business clothes. The child was absolutely delightful.
It seems that mom had noticed a huge lump on the side of her head while breast-feeding that morning. She remarked that it didn’t seem to be tender, but it had worried her so she took the kiddo directly to her pediatrician. The pediatrician sent her for x-rays, and when the radiologist saw the fracture he made a panicked call back to the pediatrician who sent mom & kid off to a pediatric neurologist. Neurologist examined her, found everything to be normal (except for a huge lump) and sent her to us for further evaluation.
I examined the child with Dr. B., mostly while mom was holding her. She was clearly well-cared for, and showed none of the stigmata of abuse - and believe me, we looked. The thing that bothered us was that no one knew how the injury happened.
The whole thing just made me nervous.
Later on that afternoon, the neurologist showed up to put his formal evaluation on the chart.
“You have to understand,” he told me, “I’m very very busy. You can’t know what it’s like - I get called all the time, twenty-four hours a day, seven days a week.” I nodded, wondering what the hell he was babbling about. “Calls like yours - I don’t have time for them. You can ask anyone; I love to teach, but I don’t have time. I’m too busy,” he said dismissively.
“Yes sir, I see. Thank you sir. I appreciate you taking the minute to explain the rationale for the imaging study to me.”
I walked away, properly chastened good little intern that I am, with a neutral insipid look on my face. I was thinking very black thoughts indeed, the least of which was “…then why the fuck are you faculty at a teaching hospital, you sanctimonious…” It had taken him longer to meander through his justification than it had to answer my question on the phone.
The social worker went into interview mom after we had finished our evaluation of the kid. A little while later she came and sat down next to me.
“You know, I really don’t have any suspicion at all. I think the chance that this represents abuse is just about zero.”
You’ve got to understand, the social worker who handles the peds floor is a goddess. She has those characteristics that seem to be common to good social workers everywhere; realistic, a bit cynical and generally nifty no matter how you cut it. I take her opinions quite seriously.
The next morning she said the same thing again to me, Dr. B. and the private pediatrician, who had come in to see the child.
The private observed, “well, all of the additional studies were normal. I think we’re done. There’s no need to go any further with this.”
“Hang on a sec,’” I interrupted, “we’ve got an unexplained skull fracture here. It’s not even like they can give us a history of the kid falling out of a bed.”
“Yeah, but I’ve known these parents for better than nine years - I take care of their other three kids.”
“That’s not the point. It’s not that I disagree with the assessment that abuse is unlikely - I don’t. But gosh would we feel silly if there were another occurrence in six or eight months. I can see the judge now: ‘So Doctor, how come you ignored the state law that mandates any serious and unexplained injuries be reported?’”
“Look - reporting something like this is pretty heavy business. You can cause an awful lot of familial strife with an unfounded report. I don’t think they need that.”
I was starting - just a little bit - to see red. “I thought we were here to take care of kids.” That earned me a sharp look from the private – she didn’t like what she thought I was implying. “We don’t need to phrase it as an accusation. Why don’t we just call CYS and tell it like it is: that we’ve got an unexplained injury, but after careful consideration, we’re not terribly suspicious. We can tell them that we just wanted to follow our own internal protocols, which mandate that we report this sort of thing, and that we’d like their pro forma input to ensure that we haven’t missed anything.”
If the social worker hadn’t spoken up again, I would have been sunk. But she did, and the rest of the team finally acquiesced, albeit grudgingly. “Okay, fine. Do what you think you have to do.”
Of course I had to pay for it – I had to explain it to the parents. I did so at length, carefully and gently. I think it took a while for them to realize that the long-haired freak in the long white coat and bolo-tie was telling them that someone from County Youth Services was going to be interviewing them regarding a fairly serious injury. They didn’t like it, but they weren’t at all unpleasant. In answer to their questions, I actually spent quite a bit of time going over various ways the injury could have happened with them, versus ways that it couldn’t have. Toppling over in the crib against the bars? No. Being dropped by an older sibling? Yes. Falling from her standing height to the floor? No. Falling against a hard step or a toy? Maybe.
Later on, I was sitting at the big table in the middle of the nursing station, writing in one chart or another. One of the nurses sat down next to me and waited until I was done scribbling. “The dad wants to know when the person from CYS will get here.”
“Um - soon, I think. I was told they were coming right out. Of course, that’s like dog-years. One bureaucrat minute is like seven of ours. Why?”
“Well, he says that both of them have jobs that are important . . . ”
I made my favorite confused idiot face at her. I do it very convincingly indeed – it seems to come naturally. “Ehh - okay,” I said, attempting a parody of MTV's Butthead. I was weighing an imaginary object in each hand. “Lessee - work,” (one hand) “skull fracture” (the other). Suddenly I became the malicious idiot. “Intern say: skull fracture!”
I leaned back in the chair for a moment and stared at the ceiling. “Am I going overboard on this? You heard when I was talking to the team - do you think I should have just let it go? I mean, when I gave the talk about abuse to the students last week, I kept emphasizing over and over again that you can’t brush these things off just because the family is well-to-do.” I stopped and looked into the room, where the little girl was giggling happily with her parents. “And you know - I really do have very little suspicion with this one. But still, I think we owe it to her – ”
She interrupted. “It’s okay. I think you did what you had to do.”
“I hope so. I mean, I don’t think this will be a problem for them - it’ll be an open and shut case, and that’ll be the last they hear of it. I think.” I looked down at the chart I was writing in, not really seeing it. “Ah, fuck. This sucks, you know? It’s not hard at all when the situation is clear cut, is it?”
“Nope.”
“This though – this just sucks.”
I’m still hoping I did the right thing.