My first mortality...

We have been warned many times to never write about work on public internet spaces like facebook and blogs. That's why I stopped writing about my tales of Residency. But I realize, I am one who likes to share life with others... my experiences, my failures, even my embarassment. So I will write and try to maintain HIPAA in my tale. I write today about an event that happened over 6months ago but still haunts me. I write the tale of witnessing the last breath a particular human being, a child, took before he met his maker. I write to tell of how poorly we as medical people deal with death and dying. I write with hope that this event will continue to leave its mark on me. He was 10years old and fairly sick. He had other medical problems, part of which complicated his care. There was very little we could have done to save him. It happened so quickly. I remember the nurse telling me she was concerned about his heart rate. I remember he had fever at the same time. I remember when I went to check him he complained his stomach hurt and he was thirsty. His abdomen looked much bigger than it was when myself and my Senior had checked him 3 hours prior. His mother told us then he hadn't passed stool in a few days but she didn't want him to get any help, "let's give him one more day." So I focused on his belly pain and talked with the Senior about getting an xray to be show his piping looked ok. I had the senior come check his abdomen. And then he started to complain that he couldn't breathe but his oxygen saturation was fine and it sounded like he was moving air ok in his lungs. We decided to get a chest xray as well. Just as I was about to step out of the room and order the xray, he took a big gasp of air and then stopped. He stopped everything. We never got him back. There are so many questions I have asked myself over the las few months... Should we have started antibiotics at the first sign of fever? Should we have given him more fluids? Should he not have been on as much pain medicine as he was? Regardless, you can't stop a fat embolism from happening. You can only give supportive care when it does happen. And hope it is not massive enough to cause an abrupt decline in health status. His mother ok'ed the autopsy that confirmed cause of death. It gave us all a little respite. He will be remembered always. And because of him, I am even more diligent with the patients under my care.

Tales of a First Year Medical Resident: Failure to thrive

'Failure to thrive' (FTT) has many definitions but it is essentially the inability of an infant or child, regardless of the cause, to gain sufficient weight to sustain growth.

I have an FTT infant on my service. He is literally skin and bones. He reminds me of the babies you see when world vision or some other NGO shows a video to raise funds for "the starving children in Africa." The only difference between my patient and these other children is he is dressed better. His weight and height are less than the 3rd percentile for his age. His head circumference is at the 75th percentile for his age. Babies heads are bigger than their bodies anyway, but this is a significant contrast.

His mom, his sole care provider, is what we call 'a difficult mother' mostly because every time the nurses feed the baby and he throws up she yells and when she feeds the baby and he throws up, she yells. She yells all the time. She is frustrated and upset with us because "we are not doing anything for my son." That in fact is untrue. Speaking of facts, let me mention a few.
Fact 1: The baby lost two pounds over a month at home, under his mother's care, became skin and bones, and it was not until he was referred to the ED by her baby's doctor that she brought him in for an intervention.
Fact 2: Since being with us (a total of 6 days) he has gained 0.34kg or 340g. Babies his age should gain 20g a day which would mean 120g in 6 days. He has actually gained much more than that, almost 3 times that amount which means something we are doing is working!!!!
Fact 3: We did some studies and found that he has significant reflux so we started him on medication and have thickened his feeds. He is still throwing up (mom told us he was doing this after every feed at home) but less so than he was at home (mother's own words).
Fact 4: I have repeatedly (almost daily) explained to mom the symptoms of reflux, and the goal of her son's hospital stay.

The baby's mother decided to have a 'yell at the doctor' session today. Who was the doctor? Your's truly. In fact she was yelling so loudly the nurse called security to ensure I was safe.

Her complaints: She's sick of being in the hospital with nothing being done for her baby. Nothing has changed he is still the same. She wants the specialist to come and take a look at him now because he threw up almost all of what he ate. She's transferring her baby to another hospital because we are not helping. We are blaming her for his weight loss.

Thankfully the baby's dad was there so I was able to speak to him and explain to him, like I had to mom every day for the last week, what we were doing, the improvement in his weight, the daily goal of caloric intake for his son, the symptoms of reflux, and why we were hesitant to jump to something more invasive when his son was indeed gaining weight. The last thing I explained to dad is that there are psychosocial elements to a baby's ability to thrive which my team and I had also spoken to mom about. If mom is depressed, anxious, unable to bond with her son, or has any medical conditions that prevent her from caring from her baby as she should, he will fail to thrive. Even the gastroenterologist had explained this to mom. We were not blaming her for his weight loss we were simply stating the facts and trying to counsel her about the effects on her baby.

Still mother wants to transfer her baby. What can I do? I am learning when to hand responsibility back to the parents/care-givers of each and every patient I have. So I explained to them it is important that the hospital they plan to go to calls us and let us know they would like to initiate the transfer before mom leaves the hospital with the baby. That way we can send over the appropriate documents. Otherwise if she walks out of the hospital she would be leaving the hospital against medical advice (AMA). Leaving the hospital AMA is never a good thing when there is evidence of improved health status of the patient in question. I have many question re: what happens in the home for my patient but my shift is over, I have taken work home with me once again and I need to get some studying done.

Until I return to work tomorrow if God wills it.

images from google images

Tales of a First year medical resident: Fracture in a pediatric patient

One of the important rules of Pediatrics is a fracture, old or new, visualized on an x-ray of a child has to be investigated. The first line of investigation is medical and key aspects of that are history taking and physical exam. If the medical team is unable to satisfy the cause of the fracture as a non-suspicious event then further prodding begins, often times ending with the involvement of child protective services. Such is the story of baby X.


Baby X is a 1 month old female with no significant medical history.


Mum notices one evening that her baby's toes are swollen. She and dad discuss coming to the ER but decide if the swelling does no go down, they will follow up with the baby's Pediatrician in the clinic the next day. The baby ends up getting admitted as a case of dactylitis (sausage digits) of unknown cause. Per the history from mother there is nothing of significance to explain the swelling; no trauma; no fever; no rash; no recent travel; no family history of joint swelling; uncomplicated birth history. In addition, mom states she is always close enough to the baby and would know if something happened. On physical exam the baby is perfect (not a medical descriptor) other than the swelling of digits. 


So the medical investigations to find the cause of the swelling begin: could it be an infection? what about some type of rheumatologic process? could it be an endocrine disorder? what about gout? There has been noted to be an association of dactylitis with pediatric tuberculosis, could it be that? All of these were ruled out with the relevant blood work and other testing. The next step is imaging so we do an xray of the feet and find fractures. 


After consulting with our child abuse specialist, child protective services are notified because this fracture has happened and there is no explanation. Enter detective work.

It turns out the baby has a 4 yr old sister who after being interviewed by the detective mentions she stepped on baby's feet while playing with him. The mechanism of injury has been identified. But the plot thickens. If Sister Y had indeed been the cause of the injury (which according to the Orthopedic specialist is entirely possible), why did baby X not have a crying fit sufficient enough to alert mum that something happened, especially if the mother is always close enough to the baby? Now the parents are being investigated for negligence and risk losing not just baby X, but 4yr old sister Y, and 10 yr old brother Z.

I'm not sure how to react. On the one side I understand the way the system works, unexplained fracture = bad thing. However, are mothers expected to attend to their babies 24/7, without stepping away? Should parents be blamed for every mishap that occurs? I know there are tons of children being abused with no one taking notice, but this situation just seems unfair...All three children have been followed faithfully by their Pediatricians with no issues. This is the first real event of significance that has happened to any of the children in that household. I would recommend that the mother be reprimanded for leaving her 4yr old alone with the baby, maybe even monitored for a few months with unannounced visits. The outcome of this case to me is a little extreme in its measure of 'justice.' But what do I know, I'm just an intern. 

All the characters in this story have been modified to protect the identity of the participants. All images taken from google images. 

Random Day 1: PDA (no its not what you think)

Today during morning report one of my Attendings said to me "Jagila I have noticed the patients with personality disorders like to come to you. They seem to like you." (I am currently doing Clinical Rotations in Pyschiatry). I was offended by this thinking he meant I had an underlying personality disorder and those patients were coming to me so we could form a club. Next thing I know he would be recommending we call ourselves 'Personality Disorders United.' Of course we would change the name to something more catchy like 'PDA (Personality Disorders Anonymous)' or something more meaningful to our diagnosis like 'We were born with hammers. Our goal is to pound the world to suit us Inc.'

So of course I joked it off. I said "that's not good"  in a comical way. The other Attending then said "No it is. It's a good thing. Patients like this like stable people and are drawn to stable people." Now I really start to get paranoid-not a good thing to be on a pysch ward. What if they are trying to rope me in and see how I react and then if I bond with these patients they will decide I'm not "fit" to be a medical student and I need to have some therapy myself. 

"Well I really need to act out then so they stop coming to me." Everyone laughs. Sigh of relief.

I've been thinking about what that means "drawn to stable people." I for one am not that stable. I have mood swings. I am lazy and inconsistent with my academic performance. I consider myself a faithful friend and yet don't keep in contact with friends for great lengths of time. I have days were all I do is watch re-runs of 'Friends' the tv show rather than interact with real people. I guess based on my understanding of what is considered stable, that is, that which is consistent, unwavering, I say I am far from stable.

This experience made me wonder what it is that other supposedly 'non-mentally ill' people consider stable compared to the mentally ill, and more so, what makes some who appear more-stable-than-others more 'appeasing.'

All thoughts welcome. 

For general knowledge

Photos from:Cartoonstock.com, Mental Health Association 
Tufts.edu