A Shout Out For Skills

You know that feeling....that feeling where you make a decision because you think it is the right one and then everyone comes down on you and wants you to change your mind? That's not a good feeling...especially on your first day as a hospitalist in a new hospital. It's better when the decision is to not have dessert and then everyone tells you you're silly for cutting calories and you should enjoy life and just eat the freakin' dessert. Much better. But I digress...

To set the stage in the vaguest possible way, I decided based on the clinical history and the impression of my colleagues when this particular baby was admitted, that I would treat for 14 days with an intravenous medication. I stress relying on the impression of my colleagues because it was a situation where I came on the scene on day 4 of admission and the baby looked very different to me than she did when she was admitted. I have faith in my fellow physicians and it does take a leap of faith to base a difficult treatment decision on a physical finding no longer present. For various reasons, this baby had to complete the entire 2 weeks of therapy in the hospital. You can imagine how the family received that news. Here is a rough approximation of how that conversation went as if you were only listening to my end...

"Unfortunately, the baby has to stay in the hospital getting this medicine intravenously for the next 9 days."
"Yes, I know all the tests were negative."
"Yes, I agree she looks great and has a normal exam today."
"I do feel strongly that this is the necessary treatment course for your baby."
"I know it is a hardship for you to drive here when you live an hour and a half away."
"You have a 2 year old at home? Wow, yes that will be tough for you."
"No, I won't change my mind on this."

It was difficult hearing the nurses whisper about what an inconvenience that was for the family and how sorry they felt for them. Difficult because I felt responsible for that hardship, it was ultimately my decision to make. A comment on a recent post of mine mentioned celebrating "the moments when I own my skills". I read that comment on the night that this happened and it reminded me that my responsibility is to ensure, as best I can, the health and safety of that baby. I own that responsibility and am grateful everyday to have the opportunity to practice my skills in this awesome career that I chose. That is something to celebrate. Thanks for the reminder.

Spare the Rod...Please

Can we talk about something sad? Not sad so much as vile and disgusting. Call it whatever adjective you will, but I have seen 4 cases of child abuse in the hospital in the past 3 weeks. These range from a broken leg in a toddler caused by 'falling off the bed' to a 3 month old beaten to within an inch of his life. When I see these children, I can't fathom what they did to incur the wrath of an adult punching, slapping, and shaking them before they even have the means to run away. It makes me sick and, i'll admit, I do pass judgment on the alleged perpetrators before they have been 'proven guilty' by a court of law. I'm human. And I have dedicated my career to ensuring the health and wellbeing of those in our society who do not have the means to advocate for themselves.

So I thought it timely when I ran across an article about spanking and domestic abuse. A study found that children who were at the highest odds of being spanked were those whose parents were aggressive towards each other. This aggression took the form of slapping, kicking and emotional abuse such as not letting the partner see his/her family. The article suggests that spanking is part of an overall 'environment of violence' in US families today. Essentially, child abuse like i've seen over the past weeks is likely a continuum of abuse stemming from the parents, who likely suffered abuse as children, who were abused at the hand of their parents, and so forth. Spanking is an act that I don't believe children can separate in their minds as discipline vs. physical oppression of another person for purpose of control. Hence, the link to abuse. The AAP has this to say about spanking:

Corporal punishment is of limited effectiveness and has potentially deleterious side effects. The American Academy of Pediatrics recommends that parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior.

I wish that I could build a dam to block the river, but instead i'm throwing life preservers to those who are drowning in the rapids.

The Voices in Your Head

I had this attending my intern year who would always send us in to see a patient and then ask, when we came out of the room, "sick or not sick?". I spent my 3 years of residency honing that skill, that gut feeling supported by experience and clinical knowledge, which allows me to assess a patient within minutes (sometimes seconds) as perhaps someone who needs more critical care than I can provide. To this day, I ask myself "sick or not sick" anytime I see a patient on the floor.

I had the opportunity to listen to this voice last week. Another physician from a hospital a couple hours away transferred a patient to me billed as more puzzling than anything. They had run multiple tests and thought they had a diagnosis and were ready to discharge her when her symptoms returned and gave them pause. I accepted the transfer and proceeded to wait for her arrival to the floor. However, there was something nagging at me. Something about the story was troubling me but I tried to reassure myself. After all, she had already been in the care of another physician who I'm sure has more experience than me. Surely they would have noticed and ruled out the very things that were scrabbling around my brain and causing me to have my 'nervous stomach'. Right??

As tends to happen on a Friday afternoon when the residents are all at lecture and I am finishing my first week on service...I walk into the room as soon as she arrives and my 'gut voice' is screaming "sick! sick! everything you thought was going on IS going on!". My gut voice doesn't have much tact, but she is phenomenally insightful. I'm learning that I should really listen to her more often. Thankfully, I had the support of the critical care team and specialists right away and she was taken to the critical care unit, where she remains today. Looking back, I should have been more focused and skeptical in my questioning of this other physician. I should have trusted my instincts and told the ICU about the patient and my suspicions before she ever arrived. As a young and fairly green hospitalist, I am quick to defer to others' judgment. This experience taught me that I can and should rely on my clinical assessment. I may not always make the right diagnosis right off the bat, but I can tell sick from not sick and that is the first step. Now I'm the attending who sends my interns into a room and asks "sick or not sick?".

Checking In (Or Taking A Break From Flogging Myself With Impunity)

Just finished my second day of my new job. Wait, has it only been 2 days?! Oy, yes it has. Not that things have been awful. On the contrary, things have been wonderful. But you know how it is when you come off of a loooonnng vacation and jump right into busting your hump and trying to look like you know what you're doing? I'm there.

My first night call is tomorrow night and i'm a bit freaked out. Not so much about the medicine....more about the finesse it takes to practice said medicine over the phone. I haven't done that in awhile so I will be exercising certain clinical muscles that are flabby with disuse. And speaking of flabby muscles....i'm not sure how I did this as a resident. By this I mean work all day running around the hospital maintaining control and order with a professional yet pleasant demeanor while fitting in teaching AND learning 'on the fly'. And then fit in a quality workout and cook a well balanced dinner. I did this as a resident, a mere 4 years ago, and I have no idea how. Because i'm certainly not doing it well now!

I'm currently propping my eyelids open and doing PREP questions on the Pedialink website. Must. Learn. Everything. But i'm not putting any pressure on myself....