Night Call

So I'm sure anyone who actually reads this is dying to know how my first week on overnight call has gone. Truthfully? Exhausting.

My shift with Awesome Partner began at 7pm, and there were nonstop admissions until 4am. It was intense, but in a good way. We saw:

A patient who coded four times, going out on his fourth code. I got to practice my compressions on this way. It was a bit surreal. I had never done it before, and a real body has a lot more give to it than those plastic dummies they teach you on.

A patient who had asymmetric facial features due to half her face being smashed in an MVA. In addition, there were possible absence seizures (she went into one in the middle of my exam, which was bizarre), and a suspected TIA. Just a really interesting case.

Yet another pancreatitis case, which must've been about the fifth in a week.

The rest of the cases weren't remarkable enough for me to actually remember them, unfortunately. But I feel like I did learn a fair bit!!

The next two days however...I literally had to try to think. After a Tuesday morning lecture, we had the rest of the day off, during which I hoped to get some sleep. Alas, no. I got about two hours of sleep the entire day, and thankfully went to bed very early because I had to be back at the hospital at 7am on Wednesday for a day shift. Hence the inability-to-think part.

Let the night shift begin!!!

Overnight call has begun...and I have a pounding headache. Oh goody.

Le sigh...maybe there's a lesson here.

After my royal hissy fit the other day about an absolutely BAD day I've had a chance to do a bit of reflecting. (This means I have thought about it constantly due to the fact that I wanted to be violently ill that entire night. Awesome Partner has said that she couldn't stop thinking about it either.)

So...with that in mind. I don't know why that day was just destined to be bad, but it was. Whoever coordinates the sh**list at Chicago Hope Hospital drew our names out of a hat on Monday and spread the word. You win!!!!!

I always try to say hello and be polite to nurses. I learned a long time ago, and have said so in numerous interviews and discussions about the practice of medicine, that nurses are a doctor's best friend on the floor. But I guess sometimes I slip, or people don't hear me, or I'm in hurry and I don't really care if I'm actually being polite because I feel like my bum is on the line. Not the best way to be, I know, but if I'm going to rant and rave about somebody else's shortcomings shouldn't I be at least marginally honest about my own? Something to work on...

The following day we indeed were working with Psycho Nurse Lady again. The next day was perfectly fine. I still don't understand WHY this nurse went off on us, because Awesome Partner said hello...and I hadn't even had the chance. I told my attending that, indeed, we were not given a chance to be polite. But it doesn't really matter does it? Perception is what is remembered--such as my perception of how I felt I was treated by the nurse and the doctor. Everyone is going to have bad days. I certainly do. But I think it's nasty how we take our bad days out on other people.

Why Did I Get Up This Morning??

10:15 this morning: My attending tries to call my partner...the call is dropped due to spotty reception on some floors at Chicago Hope Hospital. I was already going to move to a different floor, so I call her...then I lose signal. I call her back...this is what I get: "Luckyone, I'm really busy right now what do you need?"

...excuse me all to hell lady. 

Me: "Oh Hi Dr. Busy. Awesome Partner dropped the call so I was seeing what was up."

Dr. Busy: "Oh yeah...I haven't seen either of you this morning...I was waiting for you."

Me: "We had lecture at nine this morning. I wrote two of my notes before then, I didn't see you on the floor. I'm now on One Floor, Awesome Partner is on Another Floor.

 ....dead silence...doctor speaks to peeps in the back ground...blah blah blah blah CLICK!!

 Grand.

A fellow student informs me that just before I made this phone call, Dr. Busy (who is pregnant) drops her brand new iPhone (that apparently had its own drama) in between the elevator and the door...from a floor we do not round on with her. Naturally this must be my fault. It turns out she spends an hour trying to get her phone out of the bottom of the elevator shaft while I was seeing my patients.

An hour or so later (still no clue where this woman's been because both of us have been on the respective floors she rounds on) we're going to lunch and she sees us...on a floor that has nothing to do with patient care

Dr. Busy: I WAS WAITING FOR YOU IN THE ICU AT 7 AM FOR AN HOUR (PS We never round before 8, and are always called to round and FYI,  Luckyone was in the ICU at 745...no doctor)

This isn't how this rotation goes, you can't just write your note...you have to round with me." (which we do, DAILY). At this point I want to say: um, but we were ON THE effing FLOOR WAITING FOR YOU WHILE WE SAW OUR PATIENTS and this is what we've been doing for three weeks while you run off god knows where while we see our patients, and at some random, magical time throughout the day we discuss the patients with you. But you can't say that...as much as you'd love to...So you just smile and nod and feel your dignity shrink with the Greek economy...

So...that drama over with: 1pm, we get called (as usual) to the ER by the doctor to see two new patients. I go to one end, and come to find the necessary chart is at the other ER desk, where my partner has gone for her patient. I walk up to the desk, am there for about two seconds....we get accosted by one of the nurses at the desk: 

Nurse Psycho: "This just really bothers me about medical students. They just walk in and start going through things and never say hello and think they own the place..."

Awesome Partner: "Um, I'm sorry you didn't hear me say hello, I said it but you were talking and I thought you were ignoring me." 

We go see our patients and get out of the ER to get away from Psycho Nurse Lady, informing Dr. Busy that we've seen the patients, they're being admitted, and we're writing our H&Ps. She says she's coming to the floor. Half an hour later she shows up: 

"Why didn't you wait for me in the ER? Were you too afraid after being reprimanded??"

GAHHHHHHH GET BENT YOU BITCH NURSE AND BLAST ALL THE REST OF YOU NURSES WHO GO OUT OF YOUR WAY TO BE RUDE. If I say hello you act like I'm BOTHERING YOU...WHAT THE HELL DO YOU PEOPLE WANT.

I'm so sorry, Dr. Busy. Yes I INDEED made your phone fall four floors down the elevator. I indeed prevented you from getting a protective case. I HAVE THAT POWER and I can SO read your mind when you do not inform us that you want us on the floor an hour earlier than you've ever told us to be there....I'M THAT GOOD. It, assuredly, is my fault that while we were doing what we were INSTRUCTED to do...by YOU, you were worrying about your phone--a privilege I most assuredly would not be afforded--and thus I should wait to be reprimanded for not rounding and seeing the patients. I am SO sorry that I couldn't track you down by my powers of telepathy...so I had to call you to find you so we could round....and I'm on the RIGHT BLOODY FLOOR...while you are NOT

 while you drop your phone...which again is my fualt...because I HAVE THAT POWER. So sorry to interupt your day...that you then blamed me for not doing...CURSES AND ROT!!!!!! I'm so sorry that you're pregnant and ill. Even though said baby is clearly not mine...

At the end of the day, Awesome Partner and I just sat there looking at each other going...Fuck.me

I should've gone back to bed when I  rounded the corner this morning to find I would need to run to catch my bus...

Interesting cases

Complicated diverticulitis with abscess
Several appendicitis
AMS due to alcohol intoxication -- hepatic encephalopathy with serum acetone very elevated -- Pablo Personality, too

Acute pancreatitis with possible cholelithiasis

Thyroid storm

On to Round 3

This past week I began the third of my six rotations. This is a twelve week rotation of Internal Medicine. It is split up into three parts of four weeks: the first involves rounding with the hospitalist. The second night calls (can't wait). The third is ICU and outpatient. The first part, to date has been very interesting. Some days have more patients than others.
I am paired with the same person for the entire twelve weeks, and thus far I think we have gelled quite well. She is very knowledgeable and thorough, and has done a few more rotations than I have. This is good because she has so far pushed me a fair bit. I need that. I like that, and I appreciate that. We actually live a block apart so that's nice in the sense that it is easy to share transportation and study, as well as coordinate social activities as well. No complaints there. The hospitalist we are rotating with is terrific. She gives us a great deal of information and wants us to learn. I think that's great!

Syringomylia

Last week on the pediatrics floor we had a patient with a syrinx. After checking the MRI it was plain as day, and looked REALLY cool. I so much better understand the disease now having seen the MRI. Lesson learned: check the blasted imaging studies!!

Doctorese Babble -- Fluids and Electrolytes

Fluids and Electrolytes

1.     Heat loss – insensible water loss – 50%

2.     Solute loss – urine (Na, K, Cl) – 50%

100kcal --> 100mL fluid

Neonates have highest BMR – require more fluids

1.     Weight – Holiday Seey

Weight	Day	Hour
First 10kg	100mL/kg	4mL/kg/hr
Next 10kg	50mL/kg	2mL/kg/hr
Every subsequent kg	20mL/kg	1mL/kg/hr

2.     Body Surface area – more accurate but takes much longer to calculate

3.     Calculations

a.     Maintenance

                                               i.     100kcal -- 100mL H20, 3-4 meq Na, 2 meq K

                                             ii.     <3 months -- D5% + ¼ NS + 20meq K

                                            iii.     > 3 months -- D5% + ½ NS + 20meq K

                                            iv.     Bolus fluids

1.     Normal Saline

2.     Ringer’s Lactate

3.     Blood

4.     Albumin

5.     **Gatorade or Pedialite are closest to NS

6.     Do not withhold feeding

7.     20mL/kg – then reassess and repeat if needed up to 3-4 times unless edema increases (adults are 0.5-1.0L)

                                             v.     blah

b.     Deficit

	Mild 5% in neonates 3% in toddler and adults	Moderate 10% in neonates 6%	Severe 15% in neonates 9%
Tears/eyes	Sunken eyes	Sunken eyes	Sunken eyes
Membrane perf.
Skin turgor		Decreased turgor with tenting	Decreased turgoor with tenting
Fontanelle
Cap refill	<2s	<3s	> 3 s
Oral Mucosa
Urine output and spec gravity (1.010)		Decreased output and increased gravity	No output
HR	+	+	+
BP		Decreased	Decreased

c.     Ongoing losses – 10mL/kg extra fliud per loose stool

4.     I’s/O’s

a.     Urine (2:1) or specific gravity

b.     Blood à Hb, creatinine, BUN

c.     Urine osmolarity – 280-320

5.     Hypernatremic dehydration – give more fluids

Doctorese Babble: Acyanotic Heart Lesions

Acynanotic Heart Disease

- ASD most common in adults

o mostly asymptomatic due to minimal pressure difference

o Normal vitals

o Fixed split S2

o Ejection systolic murmur

o X-ray usually unremarkable

o Septum primum – sidenote

 Endocardial cushion defect

 Down’s syndrome – 30%

 30% of Trisomy 21 patients have ECD, 30% of ECD patients have Trisomy 21

 Cyanotic lesion

- VSD most common in children

o Becomes volume overload in lungs

o Full and red and wet

o Pressure difference isn’t large at birth

o As PVR decreases, L-R gradient increases

o Symptoms

 Increased respiratory rate

 Poor feeding *** -- only energy babies expend

• Will sweat around the forehead

• Poor weight gain

 Tachycardia

 Normal sats – unless severe pulmonary edema

 Biventricular hypertrophy

 Murmur

 Edema – sacral

 Crackles

o X-ray

 Cardiomegaly – cardiothoracic occupation is normally 60% in babies

 Edema

 White lungs

o Echo

 Size of lesion

 Location of lesion

• Muscular

• Membranous – will not close

 Many will close on their own – consider surgical repair if not resolved by 1-1.5 years

o Treatment

 Diuretics

 ACE inhibitors

 Surgical repair

 **Swiss cheese heart disease

- Bicuspid aortic MC congenital heart defect

- Coractation of the Aorta

o Critical if preductal – when PDA closes shock ensues

o Normal 10-20 point difference between upper and lower extremity BP – gap widens with coarct

I paid attention during anatomy lectures!!!

During an attempt to assist a resident insert a catheter on a ten month old, I thought that she was inserting the catheter in a little low...as in the vagina and not the urethra (look it up if you're not familiar with the difference...it's astonishing how many women aren't). At first I didn't say anything because 1) she's the resident and 2) I can't say I make a habit out of looking at underaged private parts--yes, I think (hope) that most balanced individuals are a bit wary and cautious of children and their parts. So I waited until attempt two went the way of attempt one--the catheter curled its way back out. I then asked if that was the vagina or the urethra. And it turns out this time I was correct.
Yay me...I can identify a ten month-old's urethra...Awkward.

Thoughts

During my family and pediatric rotations I've noticed that adults, in our infinite wisdom, frequently underestimate the raw intelligence of babies. Frequently, babies will look at you like you're a complete baffoon if you make stupid noises and faces at them. The minds of babies and children are simpler, but they aren't stupid. Engage them on their level and they will respond. A simpler level does not a mean stupid level.

I love kids, and more often than not really enjoy working with them -- even the screamy ones. Having said that, in order to effectively work with a child who is less than about eight years of age, it is essential that one just comes to terms with the facts that 1) children will scream, kick, cry, and carry on and it's not really your fault and 2) one isn't going to break them--and this gets a lot of students. This is especially true of babies. Babies bounce, folks. I don't know this from personal experience, but their skeletons are, in the medical sense, rubberized. Shaken baby syndrome is a different story, but that's also a different cause. It is very hard to cause physical trauma to a baby in the doctor's office or hospital doing a routine exam. Older children--the ones strong and aware enough to kick and fight--are still almost impossible to hurt.

Regardless, there is a reason pediatrics is a specialty. Children have different needs and in many cases different anatomy and physiology than adults. I am definitely considering pediatrics in my future. Now if only it weren't for the psycho parents...

Doctorese Babble -- Cyanotic Heart Lesions

I. Tetralogy of Fallot


A. Facts

        1. MC congenital cardiac abnormality

        2. Cyanotic lesion

        3. 1% prevalence of CDH – 1% total worldwide will receive care

        4. R-> L shunt

        5. Typically no observed immediately at birth – some decreased sats don’t always present with obviously blue appearance



B. Features

       1. RVOT – pulmonic stenosis is supra or infravalvular – clinically most important component

       2. VSD

       3. RVH

       4. Overiding aorta

C. Tet spell

       1. Infundibular spasm -- less blood circulates to the lungs  hypoxia and increased deoxygenated blood through VSD

       2. Present as grey babies with difficulty breathing – increased anaerobic respiration  lactic acid, which affects contractility and leads to cardiogenic shock

D. Treatment

      1. Sedate

      2. Fluid bolus to increase blood volume going to heart – getting the IV can be difficult

      3. Increase SVR – can reduce shunting

             a. Knee-chest positioning – compresses femoral artery and vein increasing SVR and venous return
             b. Alpha-1 receptor agonists – phenylephrine



       4. CxR shows boot-shaped heart (RVH) – decreased pulmonary blood flow  very black lungs  oligemia

       5. Echo

       6. Corrective surgery

             a. Transanular patch – pulmonic stenosis

             b. Don’t completely close VSD

                    (1) Must incise RV

                   (2) Slight VSD serves as pressure release valve, otherwise heart can fail – “blue blood is better  than no blood”

                   (3) If baby is too small, an ASD can improve saturation

           c. BTT shunt if baby is very tiny – often performed in developing countries, and can result in pulmonary hypertension if more comprehensive treatment not pursued later



II. Transposition of the Great Vessels

A. PDA can close late

B. Patients arrive cyanotic and in shock

C. Can make ASD or VSD

         1. ASD is easier

         2. PFO balloon atrial septostomy

D. “Switch procedure” ultimately curative

III. Tricuspid Atresia

IV. Truncus Arteriosus

A. Present with overcirculated lungs – edema and RSD

B. VSD murmur

C. Truncus becomes new aorta

D. RV to PA conduit


V. TAPVR

A. Peripheral veins don’t return to left atrium

B. Those that cross diaphragm frequently obstructed – pulmonary edema and RSD

          1. Bilateral edema

          2. RSD

          3. GSB pneumonia

C. Treatment – return aberrant vein to LA

VI. Hypoplastic Left Heart

Overnight Call

As part of my pediatrics rotation we are scheduled for an overnight call once a week. To date I have done two. And they have been very uneventful. Normally we are scheduled to leave at 4pm. Whoever is on call, however, stays and is literally "on call" that night. Chicago Hope Hospital provides on call rooms for each department, and we, the students, are permitted the use of one of the rooms. The rooms are very basic, but have a bed and satellite TV (which is great for me because it allows me to catch up with Roland Garros) so they are perfectly adequate. So, in essence, when the night MD trots off to the call room, the student does as well. I usually lag behind the MD a few minutes just in case something happens the minute the doctor leaves. Then I head over to the call room where I promptly change out of the clothes I've been wearing all day, and into a pair of scrubs. It is much more comfortable to sleep in scrubs (which is the point of the call room) and your clothes also don't get wrinkled--essential because you will be wearing them the next day during your rounds and commute home. My fellow students have apparently had more night action than I have, because during both of my calls the phone did not ring between the hours of 8pm and 6am, and as such I slept. Not being a night owl I am perfectly fine with being allowed to sleep all night. The next day, however, I feel grimy and gross and just want to take a thirty minute shower. Perhaps next week I will get up a few minutes early and take a quick shower before morning rounds resume. Usually "post-call" students leave around 11 the next morning.

Would I like my arse grilled or fried today?

Tis the question I always ask myself prior to rounds. No matter how hard you try, you are at the mercy and whim of an attending. If you attempt to organize it the way he just instructed a previous student to, he will change his mind. Fact. And there's nothing you can do about it. Lather, rinse, repeat tomorrow. If rounds with an attending were to be served in a restaurant the menu would look something like this: "A generous portion of your arse, your choice of grilled or fried. Served with a side helping of no-matter-what-you-say-it's-wrong. Special daily with each different attending. Degree of doneness will vary."

Doctorese babble -- Acid/Base

Acid/Base

pH: 7.35-7.45
HCO3: 24-26
CO2: 35-40

ABG: pH/pCO2/pO2/HCO3/SaO2


Anion gap = 12-16. Na – (Cl+HCO3)
Increased in anion gap metabolic acidosis



Urinary anion gap

     1. Na -(Cl + K)
     2. Normal = < 0
     3. > 0, RTA

Serum osmolarity

     1. 2Na +glucose/18 +BUN/2.8

     2. Normal = 280-300

Serum Osmolar gap
     1. Elevated gap – Ethylene glycol and MeOH
     2. Elevated = > 25

Respiratory acidosis
     1. pH < 7.35
     2. PCO2 > 45
     3. Compensation is metabolic retention of bicarb

Respiratory Alkalosis – hyperventilation
     1. pH > 7.45
     2. CO2 < 35

Metabolic Acidosis -- Diarrhea
     1. pH < 7.35
     2. HCO3 decreased
     3. Nonanion gap (<12)
          a. Diarrhea – 3rd space
          b. RTA
          c. Then measure urine AG
                 i. <0 – diarrhea
                 ii. >0 – RTA
     4. Anion gap Metabolic acidosis (>12 AG)
          a. Aspirin overdose
                i. Respiratory alkalosis first, then MA
                ii. Measure LFT
                iii. tinnitus
          b. Lactic acidosis
                i. Exercise
                ii. Hypovolemia
          c. Uremia
          d. Ethylene glycol
                i. Increased osmolar gap
                ii. Calcium oxylate stones
          e. Methanol – affects retina à color blindness à blindness
          f. DKA – hyperkalemia
Serum Anion Gap


∆∆ = Serum AG – 12 + HCO3
     1. Only calculate in AG met. Acidosis
     2. If ∆∆ < 23 – non-AG met acidosis + AG metabolic acidosis
     3. If ∆∆ > 30 – metabolic alkalosis + AG met acidosis


Metabolic Alkalosis

   *Hypochloremic state
    pH Increased
    HCO3 increased

    CO2 increased – compensatory mechanism
     1. Saline responsive
            a. Contraction alkalosis
            b. HCO3 moves to ECF due to dehydration, usually from emesis
            c. Pyloric stenosis ****
                    i. Hypochloremia
                    ii. Hyponatremia
                    iii. Metabolic alkalosis
     2. Non-saline responsive
            a. Hyperaldosteronism
                    i. Primary
                    ii. Secondary
            b. Bartter’s Syndrome
                    i. Inherited thick ascending limb defect
                    ii. Low K
                    iii. Alkalosis
                    iv. Normal to low BP
                    v. Seen 24-30 weeks gestation with polyhydramnios
                    vi. Polyuria and polydipsia postnatal
                    vii. Hypercalciuria and nephrocalcinosis
                    viii. Presentation
                           1. Chronic vomiting
                           2. Diuretic abuse
                           3. Mg deficiency
                           4. Often have elevated rennin and aldosterone
            c. Gitelman syndrome
                    i. AR kidney disorder
                    ii. Metabolic alkalosis
                    iii. Hypocalciuria
                    iv. Hypomagnesemia
                    v. LoF of thiazide-sensitive Na-Cl symporter in distal convoluted tubule
            d. ***Hypokalemia

Wow!!!

Currently on the floor at Chicago Hope Hospital is a 5 year-old with listeria meningitis. That is incredibly rare!  Dr. House eat your heart out.

Doctorese babble -- Failure To Thrive

FTT

   1.     Definition

a.     Crossing two percentile lines vertically or horizontally – 5^th and 95^th are 2 STDs

b.     Weight drops first, then height follows – if HC drops  pathological

c.     Also if Consistently below 3^rd percentile or 80^th percentile on weight vs. height

d.     Premies should be age-corrected up to two years

   2.     Causes

a.     Achondroplasia

b.     Trisomy 21

c.     GH deficiency

                                               i.     Williams’

                                             ii.     Turner’s

                                            iii.      

d.     Nutrition

                                               i.     1 oz = 30mL

                                             ii.     Should be getting 100ml/kg/day

                                            iii.     4 kg = 400mL/8 = 50mL = 1.5 oz q8hr

                                            iv.     Normal 60-80 kcal/day – Enfamil = 20kcal/oz

                                             v.     Premies/FTT/SGA/Withdrawal/Heart defects /Fast metabolism/ short bowel/ malabsorption all require increased energy needs -- 24 kcal/oz – can sometimes result in diarrhea -- discharge with Enfacare = 22kcal/oz

   3.     Inorganic

a.     Non-pathological – zero nutrition

b.     Observe a feeding

c.     15/min breast

d.     MCC of non-accidental abuse -- neglect

   4.     Organic

a.     Decreased food

                                               i.     TEF

                                             ii.     Pyloric stenosis

                                            iii.     Cleft palate/lip – special nipple

                                            iv.     Pierre Robin’s Sydrome

                                             v.     Oral-motor dysfunctions

b.     Increased metabolism

                                               i.     CHD

                                             ii.     Malabsorption syndrome

1.     Celic

2.     CF

                                            iii.     Short-bowel

                                            iv.     Small L-colon

                                             v.     Lactose intolerance

1.     Soy milk

2.     Galactosemia -- increased bilirubin

                                            vi.     Milk protein allergy – Neosure and Neoko? – rash/hives/diarrhea/melena

                                          vii.     Milk protein intolerance – only bloating and discomfort

c.     Increased excretion

d.     blaj

   5.     Infection

a.     IUGR – ToRCH -- symmetrical SGA

b.     Candida

c.     HIV ***

d.     Any other infection

   6.     Metabolic conditions

a.     Anion gap metabolic acidosis

b.     Neurological symptoms 

   7.     Neurological disorder

   8.     Lead toxicity – testing at 9 months

a.     Anemia

b.     Basophilic stippling

c.     Constipation

d.     Dust is MC source

e.     Screaming is capillary stick

   9.     Hg poisoning à fish 

   10.  Renal tubule acidosis

a.     Distil tubule

b.     Proximal tubule -- lost water and proteins – do UA  

   11.  ARPKD

   12.  Renal agensis

   13.  Reflux à hydronephrosis -- especially boys

   14.  Endocrine

a.     Hypothyroidism

                                               i.     Macrogloassia impedes swallowing

                                             ii.     Impacts metabolism

b.     Hypothalamus

   15.  Evaluation

a.     Watch a feeding

b.     Newborn screen

c.     Growth chart

d.     CMP/BMP – CBC (Infection) – glucose

e.     UA

f.      Pb

g.     HIV

h.     ToRCH titers

i.      Pre-ablumin – good indicator of feeding

   16.  Treatment

a.     Normal food à catch-up 100-120 kcal/kg -- 120ml/kg replacement – replace slowly

                                               i.     Refeeding syndrome – decreases PO4

                                             ii.     < 6 mo à increase 10-20g/day weight – weigh without diapers on the same scale at the same time