Have You Googled Today?

So, my PICU (pediatric ICU) rotation is winding down. Just one more 24+ hour call left on Saturday, and then it will be over. I plan to write a wrap up of the month on Sunday night. Today, though, post-call from the PICU, I was thinking about how much Google has changed the way I live.

I got an iPhone for Christmas. It's a fancy little gadget. Lots of buttons. Lots of memory. An ok camera in a pinch. The ability to play movies and games wherever I am. And, the all important, 24/7 connection to the internet and Google. I didn't think much about it until we took the trip to Gettysburg a couple of weekends ago.

My husband had planned things out for the most part. The route, how long it would take, etc. We used the GPS map (which, by the way is GoogleMap) on the iPhone to confirm where we were and check traffic conditions. As we got closer to the town where the bed and breakfast was we looked for a place to eat and were able to bring up a menu.

On Saturday, we used the map to guide us around the monuments in Gettysburg. When we had a question (like where were the Confederate monuments and where were the Confederate soldiers buried since they didn't seem to be at the National Cemetary - most were left on the side of the road since they were considered "traitors" but a group from the Hollywood Cemetary in Richmond, VA worked to collect them and transported a great number of the over 18,000 Confederate soldiers buried there) we would Google. We found the wax museum at the American Civil War Museum by Google. We checked out various places to eat and looked up the history of the Farnsworth House Inn.

Now, when we watch movies, we Google. We're planning for "Life after Residency" and have been Googling everything from real estate to where to mail order chicks. We've looked up draft horses for sale and have learned how to sheer sheep. We also have seen how to sheer an Angora rabbit and how to spin our own yarn.

During rounds in the PICU, I have pulled out my iPhone to check when diseases were first discovered, how to treat diabetic ketoacidosis, and what the water content is of, um, BM's (bowel movements - otherwise known as your poop. Which, by the way, is 75% water; just in case you wanted to know.)

Google has certainly changed the way I am living. So, how has Google changed your life?

Everybody Needs a Little Time Away

I haven't been writing a lot because to be honest, there really isn't much to write about in the PICU. Sure I see my patients every day, and it's really great to see a child you intubated come out on the other side extubated, doing well. But, a lot of our patients have congenital problems, and I have been carrying the same two patients for the last 2 1/2 weeks. I've had other patients come and go, but these two have remained.

So, instead of boring you with the humdrum days of the PICU, I am only writing when something interesting happens... like this weekend. My husband and I celebrated our first wedding anniversary, and he surprised me with a trip to South Central Pennsylvania. He made arrangements at the Olde Fogie Farm Bed and Breakfast in Marietta. It's a real working organic farm full of animals.

We had been talking for a while about "life after residency," and I have been talking about having chickens and some small livestock. So he wanted to show me what it might be like. The B&B organizes "chores" for the guests, so I spent my mornings feeding the animals, collecting eggs, and generally absorbing everything. I think I could get used to the lifestyle.

The other part of our trip involved going to Gettysburg. I think I learned more about the Civil War than I ever imagined I would. It was also interesting being that my husband was raised in the South, so he brought a different perspective to everything. We spent some time at the American Civil War Museum looking at the wax figures and animations. We drove around to see the monuments, mostly those from the South.

We bought a tour book and followed a part of the driving tour and somehow ended up at the brand new Gettysburg National Military Park: Museum and Visitor's Center. It had just opened last weekend, and it was awesome. There is so much to see just in the museum part that we spent several hours looking at the exhibits. There are also some multimedia and film options with admission, but we arrived later in the afternoon and just had time to walk through the museum.

The next day we drove through Lancaster County. Unfortunately, it was Sunday, so almost all of the stores were closed. Which was a bummer since I was shopping for quilts and some good dry goods to replace my stores. We did drive through some beautiful countryside and up across a part of the Appalachian trail. It was really hard coming home knowing that I would be on overnight call the next day, but I felt so relaxed and re-inspired. Sometimes, you just need that little time away.

Happy Anniversary, Honey! ILY

On Scene

As some of you know, I live in Buffalo, NY. As some of you also know I am in training to be an emergency medicine physician. I have talked about my adventures in the emergency departments of our local hospitals, and I have talked about being a part of SMART (Specialized Medical Assistance Response Team) for Erie County. We provide medical support as part of the public health and emergency response systems. We were called to action on Thursday night.

I wasn't able to go to the scene that night, but several of my colleagues did. The next day a new shift of my colleagues went to the scene. And, on Saturday, a colleague and I did. We are there to provide medical support to the hundreds of investigators, evidence collectors, workers, and firemen who are helping with the scene.

As I arrived I thought it would be bigger; larger, somehow. As I walked down Long Street I kept trying to see it. Sure, there were a line of emergency vehicles parked on the street, but still. As I tried to figure out where I was going to meet my colleague, I spotted one of our emergency trailers so I kept walking up the street. And, suddenly, there it was.

They had not been able to begin work the day before because hot spots were still being put out. Suddenly I saw the potential dangers for the workers: large and small twisted pieces of metal, pieces of wood with nails, potential sinkholes, cinder blocks that could potentially trip someone, etc. We made arrangements to be able to administer tetanus shots. We checked our suture materials. We made sure we would be able to arrange for follow-up.

And, so there I was, in the midst of the scene, starting to hear the stories.

I spent the first part of my morning surrounded by the team from the medical examiner's office, and I heard all of their plans for the day. I spent time in their tent. I watched their work.

One of the firefighters from the Buffalo Niagara Fire Department was sitting in his firetruck at the top of the scene where an airport fire truck had sat every night since the accident. I had met him during an exercise almost a year ago, and he waved when he saw me. I spent some time with him as he told me the stories related by the firefighters.

I met members of the FBI and local law. I listened to NTSB and FAA officials as they collected their evidence. Everyone wanted to talk. Everyone wanted to do more.

I was there as support, but I also watched a group of people come together and work for a common somber goal. I watched their painstaking work. I watched the respect with which each victim was handled. Suddenly, I felt the enormity of the situation. And, the scene didn't seem so small after all.

Everyone Has a Story to Tell

I know that I haven't written in a while. Despite my best efforts, I caught the "Pedi Flu." Pronounced Pee-dee, as in pee-dee-atric medicine. So, I have been snuffling and coughing along with my patients. I finally started feeling better this weekend, just in time to start my new rotation tomorrow... the Pediatric ICU. I've heard a lot of things from my colleagues, not a lot of which are positive, so we'll have to see.

I thought I would take the time tonight to wrap up this last month by talking about some of my more interesting cases. Interesting in this aspect - in college I was a journalism major because I found people's lives fascinating, and I wanted to write about them. I get to learn a tiny bit about my patients in the 5 minutes I have to interview and examine my patients. Sometimes I am just left to wonder what their home life must be like... or maybe I don't want to know... still...

Dx: CO exposure
So, we've had a flurry of these as the weather temps dip, and people start burning stuff in their fireplaces or wood-burning stoves to keep warm. Also, kerosene generators and space heaters can add to the problem. I had a mom come in with her three boys. She said the boys had been getting sick off and on over the last 2 weeks. The day before she thought she had smelled gas. She didn't know who to call, and that morning, she called her mother who told her to call the gas company.

When the gas company man arrived, he found two gas leaks. He told her to call her landlord and then get herself and the kids to the E.D. to be evaluated. While I examined her children, she told me about all the phone calls she had made to her landlord, and how she was still trying to get him to fix the leaky ceiling and clogged toilets. I turned and asked her about flushing the toilets, and she said that you had to use the plunger every time and that they were usually backing up.

Now she didn't know how long it was going to be before he would get the gas fixed. I put the two smaller kids on oxygen and wondered if I was going to have to do a social admit for the kids. After I came back in an hour and rechecked their levels, I asked her about her kids' safety and where they were going to be spending the night, she assured me that she would be going to her mother's until the gas could be fixed. She also said she had recently qualified for Section 8 and would be able to get another apartment.

I found the kids knitted hats that had been donated to the E.D. I counseled the mother about stopping smoking. (Smoking will elevate your CO level.) And, I sent them off into the night.

Dx: acute stress reaction
A mom brings her 5 year old son who has been acting strange, hearing voices, acting out in school, and falling behind because the school sent home a note. In the course of my interview and the subsequent psych interview, we learn that the mother had her mother and a sister die in a violent manner in Philadelphia.

The mom had a cousin who lived in Buffalo and was planning on getting married. She asked the mom to be in her wedding, and the mom felt the need to get away. So mom moves to Buffalo with her cousin and brings her two young sons. Five year old son misses dad and cries on the phone every night when he's talking to him.

So cousin gets into a fight with her fiance, and in the course of "needing my space" she kicks the mom and the kids out. So, mom goes to live in a homeless shelter with her two boys and ends up there for about 6 weeks. Somehow, mom manages to get Section 8 which helps her to find a new apartment, but locks her into a lease. Mom can't break the lease or she loses a lot of money. She can't get back to Philadelphia. And, now her five year old is hearing voices.

When I talk to him and ask about his friends in school, he tells me that no one wants to be friends with him. When I ask him if the voice in his head is an imaginary friend, he tells me that who would want to be friends with him. That's about the time that I felt a CT scan wasn't going to do this kid as much help as a psych consult would. Psych was able to hook the mom up with social services who would see about assisting her in getting out of her lease and moving back to Philly. That will ultimately be the cure this young boy will be needing.

Well, it's bedtime for me. I'll be rounding on a new set of patients in the ICU in the morning, and I am sure that there will be many more stories to share. Until then...

Helping the Animals

We'll return to our regularly scheduled programming after this important message for the Humane Society.

As many of you know, I have fur babies. Three of them. Sofie was my first. She was adopted from an organization in Chicago called Cats are Purrsons Too! She's been with me now for almost 6 years, and I love her dearly.

The Humane Society is holding its Spay Day 2009 Photo Contest. One is to choose the cutest pet. The second is to raise money for HSUS, HSI and many other wonderful pet organizations across the country.

I hope that you will take the time to visit the website and vote (yeah Sofie!) for my pet, enter your own pet, or support many of the wonderful organizations involved. I know money is tight, but a dollar or two can help support the spaying and neutering of all animals so that puppy mills can become a thing of the past, and all pets will find a home.

Thank you!

And please, if you enter your pets post the link so we can support each other in this fun and wonderful way!

"Sofie"

La Comedie Tragique

So I have worked a couple of more shifts in the E.D. at WCHOB, and now I am on a string of swing shifts of a sort. My sleep schedule is a bit off, so I don't know whether to stay awake or sleep in. I've been doing a little bit of both.

Anyway, there was a fair bit of drama going on during my last shift. Some of it funny. Some of it sad. Hence, the title of my blog entry today. I'll share just a few of the scenes from today's episode of "Drama: Life in the E.D."

4 year old girl. Chief complaint: bloody stools. Seems this girl was sent from her pediatrician's office with several days' history of diarrhea. Over the last two, mom had noticed bright red blood in the stools. She took her to her pediatrician who immediately sent her to the E.D. I did a thorough exam as I ran through all the possible causes in my head. When I did the rectal exam, I thought, "Now this is strange."

Now, I've done lots of rectals (not something I admit readily in public). I've seen blood in its many forms before. This wasn't blood. I didn't want to say anything until I did a hemocult card. We put a small sample on the card, and then add developer. If there's blood, it turns a dark blue color. This didn't. I still didn't say anything. The parents were looking at me expectantly. I just said, "I don't think this is blood." There were two sighs of relief. I told them to hang on a second.

I grabbed another hemocult card and brought it back into the room. Mom had collected several samples. It looked red all right, just not blood red. I put some on the other card. Again, negative. I went out to tell my attending. We looked at the sample. We looked at the card. Dad wasn't convinced so I did it again with another sample. Still negative. "Do you believe 2 out of 3?" I asked him. He smiled and said, "Yes."

Now, onto the mystery of the red poops. I asked about foods. I asked about drinks. I asked about new pills or the antibiotics the patient was taking for a recent ear infection. Anything that could have a red color dye. The mom kept answering, "No, no, no..." Then her face changed, and she smiled. Vitamins. They had just changed vitamins a few days before, about the same time the patient had started having diarrhea. All the patient liked to take were the red ones. Mystery solved. Discharged to home.

9 month old patient. Chief complaint: ? seizure. Seems the little girl had been sick over the course of the day. She felt flushed and warm to the grandmother that was taking care of her. Because it was so cold, they had wrapped the child in heavy blankets. At some point she became stiff/limp, and the grandmother got scared. They ran the child to the bath and splashed cold water all over her. She recovered, and they brought her into the E.D.

I worked her up for a febrile seizure and felt that it was from an upper respiratory infection she had been developing during the day. I was talking to the Mom and Grandmom, and they started to tell me how the reason she'd been bundled so warmly had been because the landlord was not responding to calls to fix the heater. They had been using space heaters and turning on the oven to keep the apartment warm.

I found out that we can admit children to the hospital for social or welfare reasons. We were concerned about sending a baby back out into an apartment with no heat on a night when temperatures were going to reach the single digits. However, the family told me that they had somehow managed to get the heater working again in the time they were in the E.D. (about 5 hours or so), and the Grandmom told me that she would have taken the baby home with her if that hadn't been the case. We called their pediatrician and arranged for follow-up. Discharged to home.

10 year old. Chief complaint: rash ? chicken pox. Nowadays, with the chicken pox vaccination, we're seeing less of chicken pox. I had asked if all the immunizations were up to date, which the mother assured me they were. I asked about sick contacts. I asked about other kids at school being sick. No, no. I looked at the "rash." I asked if anyone else had it.

The mother turned to an older daughter, and she showed me her lesions. I asked about family pets. A rabbit. I asked about other people's pets. Some new puppies at a friend's house. The family looked at me as if I was strange. How can a pet give you chicken pox? I said I would be right back.

I went out of the room. My attending asked me, "So, is it chicken pox?" I said, "No, bed bugs." I described the characteristic "triple bite" pattern. He went to go look while I typed up the discharge information, and a sheet about treating insect bites. At least they don't have to get rid of their rabbit. Discharge to home.

The final case: I came on shift, and one of the pediatric residents came up to me and asked me how I would proceed on a case she had. It was a 13 year old girl with abdominal pain. The pregnancy test had come back positive, and the girl had vehemently denied being sexually active. I asked if she had talked about other possible circumstances which would allow the meeting of sperm and egg, and the resident said, no she hadn't asked.

I asked if she had done an ultrasound. She asked, "We can do that?" I told her that as E.D. residents we always put an ultrasound on anything we want a quick and easy answer for. I offered to do it for her. She said, "Yes." So I went into the room and introduced myself. I told them I was just looking to see if there were any obvious abnormalities.

The mother kept joking, albeit with more worry than laughter in her voice, about finding babies and how there had better not be any. The daughter kept saying, "No way" and then asking me if I was seeing anything abnormal. I told her that I didn't see anything abnormal, and that her resident still might want to do a more formal ultrasound. We got back the blood pregnancy test that confirmed there was a pregnancy. The number of the count was low, so too small for me to even see the beginnings of what is known as a gestational sac.

As the shift progressed, I asked the peds resident what had happened. Before sending the girl to ultrasound for a formal scan, she had told the girl that she was pregnant. The girl started crying and then admitted that she had a 16 year old boyfriend, and that they'd been having sex for 2 years. Something about the thought of an 11 year old girl having sex left me unsettled for some reason. I tried to think back to when I was 11; boys were still icky annoyances.

There was no badness on ultrasound (meaning no ectopic), and after OB-Gyn came down for a consult (pelvic and mom finding out the diagnosis) the patient was discharged to follow-up with her pediatrician and to get a prescription for chemical pregnancy termination. I won't discuss my thoughts on that issue, but suffice it to say that given what I see from day to day, I think it's the right decision for all involved. Sigh.

Time to get ready for another shift. Seriously, I am hoping to see something more interesting than colds and diarrhea. When is the RSV season over...?

Under Pressure

I never thought about the change that would happen in six months.

I just started my next rotation at Women and Children's Hospital. After almost two months working at ECMC, I think I was ready for the change. However, I didn't expect quite the change.

If you've been following my blog, you know that I have already done two rotations as an intern at WCHOB. And, despite the fact that I really don't like kids, I actually enjoyed them. It gave me a chance to do some preventative medicine - which I think is very important, a chance to teach - which I love to do, and, for the most part, I learned a lot about pediatric acute (and some not so acute) emergency medicine.

However, starting on Monday morning, I was the "senior" emergency medicine resident. Suddenly, it wasn't about "what does this child have?" it was about "how are you going to fix them?" Having not seen anyone under the age of 16 for the last 6 months, I really found myself rusty in my diagnostic skills, and with the added pressure of making more complex decisions about their health care, I was really at a loss my first shift.

What did not help was the fact that it was Monday. In January. At the height of RSV and flu season. And, I had an intern that had never been to WCHOB before. And, we started the morning with a trauma. A sixteen year old girl T-boned on her way to school at 45 mph. She ended up with a subdural hemorrhage. By the time we finished assessing her, we had four new patients on the board, and the fun was just starting.

I felt like an intern, trying to get used to the system again. Trying to manage the patients. Trying to just feel like I wasn't sinking. We got more residents in over the next 4 hours, but the whole system was just overloaded.

At one point we had all 26 rooms full. They opened another section of rooms (+6). And the waiting room had about 20 people waiting. The computers crashed, the nurses were surly as they were being pushed to their limits, and ambulances kept bringing people in.

We had the comic "E.R." moment when everyone was running around, a barely-breathing baby is brought into the back and starts being coded, the ambulance rolls in with another child turning blue despite ventilation, and the noise level rises to fever pitch. The baby is taken to another room so that the blue child can be rolled across the work station to the now vacant code room, and there's the rush and flurry of the respiratory therapists pushing ventilators as the radiology techs push around their giraffe-painted x-ray machines.

I left that night with 4 patients waiting to go to the Pediatric ICU (PICU), another 5 or waiting for admission, and a full board (20+) in the waiting room to be seen. You don't learn in that environment. You just try to survive and not let anyone else get hurt.

My next shift was a little better. At least I was able to think about my patients more. Review my disease processess. Come up with a plan before presenting to the attending. Not to mention, I actually knew the attendings. One of our complaints about WCHOB is that we're working with pediatric attendings who have completed a fellowship in Pediatric emergency medicine. We're guests in their house.

They've hired a whole group of new graduates, none of which I had worked with before. Not that it makes a whole lot of difference, but you get used to how an attending likes their work-up and presentation. You know who lets you fly and who keeps a close rein. I guess I could have almost called this posting "Out of my comfort zone."

Sigh. It was just the first two days. I work tonight (which is another problem, since we don't schedule our residents we get whatever schedule the pediatric chiefs come up with which doesn't always make sense or take into account shift time changes.) I know I will be able to get back into a rhythm. And, I know that by the end of the month, I will be a lot more comfortable with what I am doing in my new role.

Just in time to start my PICU month when the fun begins anew!

Until then, we'll see what interesting stories that don't involve coughs, colds, vomit, diarrhea and parents that should need a license before they're allowed to procreate we can come up with.

As for the video above. I like the way they combined two of my favorite shows "Grey's Anatomy" and "Scrubs" And, I like the song....