Sunday, October 07, 2007


I started my sub-internship in the intermediate intensive care unit at our children's hospital on Monday. It's been...intense. Today is my only day off for the first three weeks of October. I take call every fourth day. Monday I admitted three patients overnight, and rounded on them in the morning. At noon Tuesday I found out that I would have to round on four new patients Wednesday in addition to my patients. Essentially, it meant that Wednesday morning I had to round on six patients, all very complicated, four of whom I knew nothing about. My presentations were shaky at best. I stayed two hours late that day to go over their charts (some had been in the hospital for several months) which aided considerably in rounds the next morning. Friday I took call again--I admitted 5 new patients overnight, giving me nine patients total. As these patients are all far more complicated than any patients I've taken care of before as a third year medical student (virtually no real responsibility) it's been challenging. I've been told that I'm doing well fortunately, and I think the fact that I'm working hard even though I'm not going into peds helps my reputation as a sub-i a lot.

Some of my patients over the last week:

1) Ten year old boy w/new onset diabetes presenting in diabetic ketoacidosis. Gave him a lot of IV fluids and IV insulin, sent him home two days later.

2) 18 yo girl with Charcot-Marie-Tooth disease (neurological disorder). She's ventilator dependent, but very stable. We have her because there was a question of negligence on her parents' part--they are fighting to keep her. Lot of messy social stuff, but my gut feeling and the feeling of the attendings is that her parents are being unfairly judged, and she will most likely go back to them, hopefully this week.

3) 3 yo girl with history of congenital heart disease, underwent repair several years ago, here with heart failure. Worsened after tonsillectomy. Slowly improving, though has a lot of stuff going on and will need to be very closely followed when she leaves.

4) 3 yo girl with congenital heart defects, needs a new heart. She's been here for months just waiting. A few nights ago I started praying that she would get a new heart, but then suddenly realized that for that to happen, a healthy child somewhere is going to have to die. Very sad situation.

5) 10 yo girl with extensive medical history, had a bilateral lung transplant several months ago. A couple of her labs from home were a little off, so she was admitted with the concern of a line infection. She's completely asymptomatic, but as she is immunosuppressed there is still a concern. Hopefully the concern is baseless and she'll go home soon. Interestingly, she has an incredibly bizarre diet in which she eats horrendous amounts of food, but remains a normal-sized ten year old. Apparently, she eats every couple hours, and will sit down and eat five hamburgers at a time, or will order 75 pieces of salami and eat them in one sitting, dipping each piece in salt, etc. There's a suspicion that she may have a biotinidase deficiency.

6) 4 yo girl with neurologic devastation after complete cardiopulmonary arrest a year ago (she was totally normal before), believed to be secondary to parental abuse (also has history of a couple broken limbs which is a serious red flag). She is trach and g-tube dependent, has spastic limbs, cannot communicate, and has a seizure disorder. She's in foster care now--her parents legally have custody, but are not allowed to be alone with her. She had an episode the morning of her admission in which she stopped breathing, was bagged for five minutes, then revived and has been fine since. We think that her trach was momentarily clogged with a mucus plug. Her mother came to spend the night in the hospital with her, and acted like a concerned parent--her foster mom told me that despite the fact that her parents have full visitation rights, this was the first time she had met the biological mother. I didn't have a lot of sympathy for the biological parents, and had to bite my tongue when I heard the biological mother complain on the phone about the court system.

And I have several more. The vast majority are far more complicated than I am comfortable with, and honestly I have a very limited understanding of what the full scope of their disorders are. This is a pretty intimidating rotation, and even though I know I'll learn a ton, and I'm grateful for the fact that it really pushes me to be far more efficient than I've ever been before, and to know my patients well, I can't help wishing every once in a while (usually at 2:00am when I've done 3 admissions and have two more coming) that I did the family practice sub-i instead, which caps at two admissions a night and has patients with simple problems:). I have learned that I really prefer to deal with patients with one acute problem, with maybe the occasional well-controlled chronic problem as opposed to here where patients have 5 medical problems and take 30 medications every day. Maybe that will change over the years as my knowledge increases and my general competency improves. One really weird thing about this rotation is for the first time I am the first point of contact for my patients for the nurses--they ask me questions about what they should do, and expect me to have an answer. This is particularly difficult at night when I am covering almost 30 patients, and don't know most of them. Thankfully, there is a senior resident available who has to sign all my orders, and is available if I need help with something.


Blogger Helen said...

It sounds like you will learn a lot on this rotation. The fact that you are willing to ask questions when you don't know the answer to something is honorable.

6:01 PM  

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