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Sunday, August 23, 2015
Best Friends
The End of Rotation #1
Friday was my last day at Children's Oakland. It was not only my rotation with the longest hours but also the most challenging rotation I've had thus far, including all of my third year rotations. Though extremely tiring, it was also the most rewarding rotation so far in all aspects.
On my last day, my first ever patient was finally discharged home. He was admitted on my first day ever in the NICU 4 weeks ago and on this past Friday, he and I both left the hospital together. It's such an eerie coincidence but I can truly say that I will never forget this little baby and everything he and his mom and dad went through. I became friends with this family during this time and I wish the best for them moving forward. I also told my senior resident that if I have the chance to come back to this hospital as a resident next year, I'm taking him back as my own clinic patient! How crazy would that be. All the best for this little kiddo. He had a tough first 4 weeks of life.
One of the things I'll miss most are my residents and Attendings. I worked with some really incredible residents and Attendings during my third year especially on my Surgery and Internal Medicine rotations and the people at Children's are right up there with the best. On Friday, my senior not only wrote me an amazing thank you card but she also baked me a lemon tart pie. Unheard of! I was so grateful.
It's onward toward my next rotation now. So long Children's Oakland, I hope I can return soon!
On my last day, my first ever patient was finally discharged home. He was admitted on my first day ever in the NICU 4 weeks ago and on this past Friday, he and I both left the hospital together. It's such an eerie coincidence but I can truly say that I will never forget this little baby and everything he and his mom and dad went through. I became friends with this family during this time and I wish the best for them moving forward. I also told my senior resident that if I have the chance to come back to this hospital as a resident next year, I'm taking him back as my own clinic patient! How crazy would that be. All the best for this little kiddo. He had a tough first 4 weeks of life.
One of the things I'll miss most are my residents and Attendings. I worked with some really incredible residents and Attendings during my third year especially on my Surgery and Internal Medicine rotations and the people at Children's are right up there with the best. On Friday, my senior not only wrote me an amazing thank you card but she also baked me a lemon tart pie. Unheard of! I was so grateful.
It's onward toward my next rotation now. So long Children's Oakland, I hope I can return soon!
Monday, August 17, 2015
Cardiothoracic Surgery
This story that I came across today really struck me. There are so many pediatric patients who need cardiothoracic surgery, usually because they have congenital anomalies of the heart that are incompatible with life if they don't undergo surgery or for some other medical reason. I've seen a few babies who need cardiothoracic surgery and just today, our team added another one onto the schedule. I'd like to believe that surgery programs in the United States are adequately trained to perform these highly complex surgeries as finishing a pediatrics cardiothoracic surgery fellowship is an extremely long ordeal, probably one of the longest in the medical profession. Unfortunately, after watching this video, that may not be the case. That's not to say that there is never a risk to these operations; in fact, the risk of complications from surgeries can be quite high. I'd just like to believe that when parents consent their babies to invasive surgery, it's to a program where the surgeons are well-practiced and where risk is minimized to be as low as possible.
Sunday, August 16, 2015
Attachment
Today, one of my very first patients finally left the hospital after a two week stay in the NICU. She was an adorable little girl with the sweetest mom and dad who would come stay with her in the hospital every afternoon. She underwent an extremely invasive and rough surgery but came out like a rock star. After 10 days of recovering, I'm so happy that I got to see her go home and be with her loving family.
Though it's hard to measure, it must be tough being in the hospital for such young babies. The environment is noisy and every day there are a handful of random people staring at you, feeding you, changing your diaper, and moving you around. Usually, a stay in the NICU will run at minimum about two weeks, most likely a lot longer. Most stays will also involve some invasive procedure as well. I can't imagine the stay in the NICU being like a vacation!
Since babies usually stay on the service for a good amount of time, we get extremely attached to them. When they're doing well, we're happy and when they're having a rough time, it makes us worry like no other. Sometimes, we wonder how we can fix them and wonder why we can't figure out what's causing them to be so sick. Medical school always taught me how to treat the diagnosis but what happens when you literally cannot find the diagnosis, even with some of the brightest doctors working on the case together? Medical school never taught me that part.
Though it's hard to measure, it must be tough being in the hospital for such young babies. The environment is noisy and every day there are a handful of random people staring at you, feeding you, changing your diaper, and moving you around. Usually, a stay in the NICU will run at minimum about two weeks, most likely a lot longer. Most stays will also involve some invasive procedure as well. I can't imagine the stay in the NICU being like a vacation!
Since babies usually stay on the service for a good amount of time, we get extremely attached to them. When they're doing well, we're happy and when they're having a rough time, it makes us worry like no other. Sometimes, we wonder how we can fix them and wonder why we can't figure out what's causing them to be so sick. Medical school always taught me how to treat the diagnosis but what happens when you literally cannot find the diagnosis, even with some of the brightest doctors working on the case together? Medical school never taught me that part.
Friday, August 7, 2015
Diagnosis 101: Necrotizing Enterocolitis
I wanted to start a fun segment like this because the nerd in me loves to talk about cool diagnoses. I thought it would be really interesting to document some of the cool cases that I see this year because it'll help me remember how to diagnose, treat, and manage my patients better in the future and hopefully it'll be fun for other people to learn about.
Of course, as a disclaimer, I'm only a medical student so it's not meant to be anything professional and I'm writing this all from memory based on what I learned in the hospital.
Today, I chose to write about Necrotizing Enterocolitis, or NEC, because it's one of the most feared feeding complications in a neonate and from what I was told by my Attending, one of the most feared diagnosis for a neonatal intensivist. NEC is basically a bacterial infection of the intestinal wall, usually in the right colon but can really happen anywhere. The infection causes necrosis which is death of tissue in the intestinal wall which can lead to pretty bad consequences for the baby. Normally our gut wall serves as a barrier, it keeps the gut bacteria in its own compartment, the GI tract. When the gut wall becomes necrotic, gut bacteria, other life-threatening bacteria, your stool contents, and basically everything that shouldn't cross the gut wall can now do so. If untreated, NEC can cause perforation of the gut wall (never a good thing...terrible in fact), sepsis (an overwhelming inflammatory response of the body), and death. The mortality rate for NEC is probably greater than 25% or even higher for babies with more severe infections.
Why are some babies at higher risk for developing NEC? It's been shown that premature babies are increasingly more likely to develop NEC. The more premature a baby is, the higher the likelihood, and that's simply because the intestines are that much more immature and underdeveloped compared to a full term baby. On top of that, feeding a premature baby formula further increases the risk of NEC. The research in this area has been so solid that doctors now recommend feeding the baby donor breast milk if the mom's supply hasn't come in yet rather than risk formula feeds. Donor breast milk, like blood, is also screened multiple times for harmful substances and molecules so it's really safe!
So what are the signs that maybe a baby is developing NEC? From what I've been taught, NEC can show up in several different ways. One is abdominal distention. When a baby's stomach gets tense, firm, and large, you should worry. Another is bilious emesis - a fancy term for yellow/greenish vomit. It's okay for babies to regurge a bit of white-ish colored milk but once they start vomiting higher volumes of yellow/green digested looking milk, that's not a good sign. A third sign is bloody stools which is what I saw in my patient. Usually a small amount of blood that shows up as red streaks in the diaper is not that concerning - you might think about something like an anal fissure which can cause the blood vessels around the anus to tear as the baby tries to poop. However, if the baby passes more and more stools containing blood, it becomes more worrisome. In our case, I eventually saw frank, bright red bloody diapers.....uh oh. There are signs that are more generic too and these are just signs that lead you to think of infection somewhere in the body - a fever of greater than 100.4 degrees (I can't emphasize how important it is that parents keep a working thermometer somewhere in the house), a fast heart rate, increased work of breathing, and perfusion of the body. Some of these are harder to pick up as babies normally have fast heart rates and fast respiratory rates anyway - which is why as a parent you have to be very in tune with how your baby acts and reacts.
Once you suspect a possible NEC infection, what's your next step? In other words, what do you do to diagnose the neonate? Answer: Get a KUB - a Kidney - Ureter - Bladder X-ray. The most important part of this is that you must get a KUB in two dimensions - usually one with the baby lying on his or her back and another one lying on the L side (called a left decubitus view). The importance of this lies in the fact that you can easily miss the diagnosis of NEC or miss the appearance of free air if you only get one view. Note: Free air is bad!!!! Free air equals a surgical emergency. It means that you've perforated the intestinal walls so that the air from inside the intestines is now leaking out. So on the KUB, besides for looking for free air, you also want to look for pneumatosis (air in the intestinal bowel walls) and portal venous air (air in the veins going into the liver). I found two awesome pictures courtesy of Dr. Frank Gaillard and Dr. Jeremy Jones on Radiopaedia.org - one of my favorite sites to look at x-ray images.
Now that you've made the diagnosis of NEC, how would you treat it? There are two ways to consider treatment. 1) The first is more conservatively: medically with antibiotics - ampicillin, gentamicin, metronidazole all by IV. These three antibiotics cover the three big groups of bacteria: gram-positives, gram-negatives, and anaerobes. The typical course is 10 days of antibiotics. While being on these medications, you also absolutely cannot eat anything by mouth so we put the patient on NPO "nil per os." This is super important because after you get NEC, any food or liquid that go into the intestines will aggravate the body and will make the infection even worse. Since the baby can't eat now, we also will give the baby TPN (Total Parenteral Nutrition) which is your basic calorie needs through a central IV line. The last is putting in a NG or OG tube. A NG or nasogastric tube is a small tube inserted through the nose until it rests in your stomach and similarly, an OG or orogastric tube is one that's inserted through the mouth into the stomach. Both tubes function to suction fluids out of the intestines because even though you're not
eating or drinking anything, the body naturally continues to secrete
fluids into your stomach and intestines so it's important to get all of
that out. 2) The other way to treat is surgical. This is a big step as undergoing surgery is never an easy process and has a whole bunch of risks in and of itself which I won't discuss now. The surgery functions to resect or cut out all of the necrotic or dead intestine segment and a) try to join the remaining two pieces together or b) create an ostomy (bringing an end of the intestine straight out into the open skin layer) and then doing a takedown 6 to 8 weeks later after the intestines have healed. A takedown is essentially connecting the two pieces of healed intestines back together again. I found a short video which you can watch here that kind of show how sick these kids that undergo surgery for NEC usually are. It really can be a disastrous, life-threatening disease if not caught early!
Anyway, all of this is pretty crazy. Who would've thought that in my first rotation in the NICU, I'd be able to see a case of NEC? Now I won't forget!
Of course, as a disclaimer, I'm only a medical student so it's not meant to be anything professional and I'm writing this all from memory based on what I learned in the hospital.
Today, I chose to write about Necrotizing Enterocolitis, or NEC, because it's one of the most feared feeding complications in a neonate and from what I was told by my Attending, one of the most feared diagnosis for a neonatal intensivist. NEC is basically a bacterial infection of the intestinal wall, usually in the right colon but can really happen anywhere. The infection causes necrosis which is death of tissue in the intestinal wall which can lead to pretty bad consequences for the baby. Normally our gut wall serves as a barrier, it keeps the gut bacteria in its own compartment, the GI tract. When the gut wall becomes necrotic, gut bacteria, other life-threatening bacteria, your stool contents, and basically everything that shouldn't cross the gut wall can now do so. If untreated, NEC can cause perforation of the gut wall (never a good thing...terrible in fact), sepsis (an overwhelming inflammatory response of the body), and death. The mortality rate for NEC is probably greater than 25% or even higher for babies with more severe infections.
Why are some babies at higher risk for developing NEC? It's been shown that premature babies are increasingly more likely to develop NEC. The more premature a baby is, the higher the likelihood, and that's simply because the intestines are that much more immature and underdeveloped compared to a full term baby. On top of that, feeding a premature baby formula further increases the risk of NEC. The research in this area has been so solid that doctors now recommend feeding the baby donor breast milk if the mom's supply hasn't come in yet rather than risk formula feeds. Donor breast milk, like blood, is also screened multiple times for harmful substances and molecules so it's really safe!
So what are the signs that maybe a baby is developing NEC? From what I've been taught, NEC can show up in several different ways. One is abdominal distention. When a baby's stomach gets tense, firm, and large, you should worry. Another is bilious emesis - a fancy term for yellow/greenish vomit. It's okay for babies to regurge a bit of white-ish colored milk but once they start vomiting higher volumes of yellow/green digested looking milk, that's not a good sign. A third sign is bloody stools which is what I saw in my patient. Usually a small amount of blood that shows up as red streaks in the diaper is not that concerning - you might think about something like an anal fissure which can cause the blood vessels around the anus to tear as the baby tries to poop. However, if the baby passes more and more stools containing blood, it becomes more worrisome. In our case, I eventually saw frank, bright red bloody diapers.....uh oh. There are signs that are more generic too and these are just signs that lead you to think of infection somewhere in the body - a fever of greater than 100.4 degrees (I can't emphasize how important it is that parents keep a working thermometer somewhere in the house), a fast heart rate, increased work of breathing, and perfusion of the body. Some of these are harder to pick up as babies normally have fast heart rates and fast respiratory rates anyway - which is why as a parent you have to be very in tune with how your baby acts and reacts.
Once you suspect a possible NEC infection, what's your next step? In other words, what do you do to diagnose the neonate? Answer: Get a KUB - a Kidney - Ureter - Bladder X-ray. The most important part of this is that you must get a KUB in two dimensions - usually one with the baby lying on his or her back and another one lying on the L side (called a left decubitus view). The importance of this lies in the fact that you can easily miss the diagnosis of NEC or miss the appearance of free air if you only get one view. Note: Free air is bad!!!! Free air equals a surgical emergency. It means that you've perforated the intestinal walls so that the air from inside the intestines is now leaking out. So on the KUB, besides for looking for free air, you also want to look for pneumatosis (air in the intestinal bowel walls) and portal venous air (air in the veins going into the liver). I found two awesome pictures courtesy of Dr. Frank Gaillard and Dr. Jeremy Jones on Radiopaedia.org - one of my favorite sites to look at x-ray images.
| Pneumatosis intestinalis: Red arrow points to the "tram-track" appearance of the bowel wall layers - very diagnostic for NEC |
| Portal venous air: Usually the liver should be a homogenous color. In this case, you can see the air (a different density compared to the liver) show up on top of the liver. |
Anyway, all of this is pretty crazy. Who would've thought that in my first rotation in the NICU, I'd be able to see a case of NEC? Now I won't forget!
Thursday, August 6, 2015
The Art of Pediatrics
Pediatrics is a crazy specialty in so many different ways.
Which other specialty will gather around a baby on rounds (Attending included) and collectively go awwwwww
Where else would a blood pressure of 60 systolic be completely okay for the patient?
Congenital diseases. Oh my goodness. This is where all the cool medicine happens. Pediatricians are the first to receive and diagnose these kids! (Think House) Even if you see an adult patient who has a congenital disease, they almost 100% would have had it diagnosed already....and if they haven't, they are most likely dead - unfortunately.
You basically have to know the development of the human body like the back of your hand. From fetus to neonate to infant to child to teenager to young adult. That's only about 18-20 years and approximately 25% of your life but everything about the body changes in that amount of time.
Wait, you can do a lumbar puncture without a CT scan first? Even if there's edema in the brain?? Even if there's a midline shift??????? Well, only for babies until their fontanelles close I suppose..but still, how cool is that?
I'd like to think that pediatricians play the greatest role in protecting society. Immunizations anyone? In my opinion, the single greatest advancement in modern medicine. Although it can sometimes be quite frustrating dealing with parents who don't want to vaccinate, pediatricians are still the ones at the forefront, trying to give kids their shots at the right time. Case in point: Spain 2015
I can't understand why this still happens. The parents are never going to forgive themselves.
Crazy isn't it?
Which other specialty will gather around a baby on rounds (Attending included) and collectively go awwwwww
Where else would a blood pressure of 60 systolic be completely okay for the patient?
Congenital diseases. Oh my goodness. This is where all the cool medicine happens. Pediatricians are the first to receive and diagnose these kids! (Think House) Even if you see an adult patient who has a congenital disease, they almost 100% would have had it diagnosed already....and if they haven't, they are most likely dead - unfortunately.
You basically have to know the development of the human body like the back of your hand. From fetus to neonate to infant to child to teenager to young adult. That's only about 18-20 years and approximately 25% of your life but everything about the body changes in that amount of time.
Wait, you can do a lumbar puncture without a CT scan first? Even if there's edema in the brain?? Even if there's a midline shift??????? Well, only for babies until their fontanelles close I suppose..but still, how cool is that?
I'd like to think that pediatricians play the greatest role in protecting society. Immunizations anyone? In my opinion, the single greatest advancement in modern medicine. Although it can sometimes be quite frustrating dealing with parents who don't want to vaccinate, pediatricians are still the ones at the forefront, trying to give kids their shots at the right time. Case in point: Spain 2015
I can't understand why this still happens. The parents are never going to forgive themselves.
Crazy isn't it?
Wednesday, August 5, 2015
From A Patient's Perspective...
Now, more than ever, I realize how scary it can be for someone who
doesn't have a background in medicine to be admitted to the hospital.
It's even scarier to be a parent and watch your child be admitted. My
whole life I've always thought that raising a baby, at least until
they're around age 3 or 4 would be a pretty easy thing to do. What do
babies do? They eat, sleep, cry, babble, crawl, and walk. Pretty easy to
deal with. Never have I been scared to be around babies, to hold them,
to change their diapers, or to feed them. Raising a healthy baby should
be a pretty easy thing to do right?
But now, for the first time, I'm seeing everything that can go wrong in the health of a newborn baby. Of course, some of it can be attributed to the parents (note: cocaine use and pregnancy should never occur at the same time), but some of it has absolutely nothing to do with the parents at all. Sometimes, even though mom and dad are perfectly healthy, babies can develop abnormally and quite frankly, it's nobody's fault and there's no reason for it. In the last few days, I've really seen how scary it is for parents to see their precious newborn baby decompensate right in front of their eyes. It can be something as simple as a sudden vomiting episode or a just a feeling that maybe the baby is a bit more lethargic than yesterday. Even a sudden temperature of 100.4 (something that wouldn't normally be a huge issue in adults) can be worrisome in newborns. For each of the three clues I just listed, I've now seen cases where the baby was admitted to the NICU and it turned out to be so much worse - real issues that meant the difference between life or death for the baby. Perhaps if the parents had brought the child in one day later, he would've died...if they had brought him in one day earlier, he would've lived.
Watching these parents with their babies, I can't help but imagine myself as a mother and having to watch my own kids go through the same thing. It's impossible. What must they be thinking when the nurses are poking their baby for blood? When the doctors come around to round and speak in what seems to be a completely different language? What do they think when they don't see or speak to a doctor for hours or even days at a time while they watch their baby helpless and lifeless in the crib? I'm seeing so much of this play out in the NICU and I've realized it's such a difficult scenario to grasp unless you're in the shoes of the parents or unless you have an understanding of how physicians function in the hospital.
As a medical student, I'm often in between the parents and the physicians. Sometimes I might even spend more time talking to the parents and relaying information if rounds occur when the parents are not beside their baby. One thing to point out though is that even though parents might not see the doctors around all the time, they are always up to date on the baby's status and on what's going on. At Children's Oakland, these Attendings and residents are on top of their work in the NICU. Rarely do they take a break and that's only usually for some food and coffee to recharge. From my end, I just hope that I'm doing enough to help these parents understand what's going on with their baby and help them realize that the medical team is doing everything to make sure that the baby can return home in good health.
But now, for the first time, I'm seeing everything that can go wrong in the health of a newborn baby. Of course, some of it can be attributed to the parents (note: cocaine use and pregnancy should never occur at the same time), but some of it has absolutely nothing to do with the parents at all. Sometimes, even though mom and dad are perfectly healthy, babies can develop abnormally and quite frankly, it's nobody's fault and there's no reason for it. In the last few days, I've really seen how scary it is for parents to see their precious newborn baby decompensate right in front of their eyes. It can be something as simple as a sudden vomiting episode or a just a feeling that maybe the baby is a bit more lethargic than yesterday. Even a sudden temperature of 100.4 (something that wouldn't normally be a huge issue in adults) can be worrisome in newborns. For each of the three clues I just listed, I've now seen cases where the baby was admitted to the NICU and it turned out to be so much worse - real issues that meant the difference between life or death for the baby. Perhaps if the parents had brought the child in one day later, he would've died...if they had brought him in one day earlier, he would've lived.
Watching these parents with their babies, I can't help but imagine myself as a mother and having to watch my own kids go through the same thing. It's impossible. What must they be thinking when the nurses are poking their baby for blood? When the doctors come around to round and speak in what seems to be a completely different language? What do they think when they don't see or speak to a doctor for hours or even days at a time while they watch their baby helpless and lifeless in the crib? I'm seeing so much of this play out in the NICU and I've realized it's such a difficult scenario to grasp unless you're in the shoes of the parents or unless you have an understanding of how physicians function in the hospital.
As a medical student, I'm often in between the parents and the physicians. Sometimes I might even spend more time talking to the parents and relaying information if rounds occur when the parents are not beside their baby. One thing to point out though is that even though parents might not see the doctors around all the time, they are always up to date on the baby's status and on what's going on. At Children's Oakland, these Attendings and residents are on top of their work in the NICU. Rarely do they take a break and that's only usually for some food and coffee to recharge. From my end, I just hope that I'm doing enough to help these parents understand what's going on with their baby and help them realize that the medical team is doing everything to make sure that the baby can return home in good health.
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