Quiet Call Day

Today's been really a quiet day. One of the things that I love about being on call in the NICU (OK, I just generically love the NICU) is that there's bedside nurses for all of the patients. If I want the nurse, I can just walk to the bedside and talk to her (there's about four male nurses in a cohort of several hundred NICU nurses and none of them are working today.) This is great for collaborating with the nurses on the plans, and also just creates a really nice work environment. I know most of their names (on my side of the NICU there's two residents, about 5 NPs and probably 75 plus nurses; I try to know all of their names, but it's hard.) They all know me. If I want something, I can go and talk to them face to face, without needing to call or page to find them. I walk around every 4 hours, or so, to check in and it goes quickly and I feel involved and in the loop and like a good doctor.

Most floors aren't like this -- most floors some nurses change at 7am and some at 11am and some at 3pm and some at 7pm and some at midnight and it's hard to know which nurse has whom and if you can't find the nurse, there's a million places where s/he might be. It's harder to be a team.

Since it was so quiet, I was chatting a lot with the nurses, mostly about them and their lives, but also about being on call and what it's like. The fact of the matter is that I like my life with call a lot more than any of the alternatives. I like that for a total of 28 hours, I'm really the doctor for these babies (I have a fellow and an attending, but they're mostly only involved when I call them.)

And there's an asceticism to taking call that can be very rewarding in an odd way. Expelled through the hospital doors in the morning, sleep-deprived, blinking in the bright sunlight, having been in artificial lighting for the last 28 hours, shockingly warm after 28 hours of frigid air-conditioning, you feel reborn into the world. Little pleasures like breezes and being able to eat whenever you feel like it feel poignant.

It's my last call for a month, before I go to the emergency department. I'm a quarter done with calls for the entire year (an advantage of being in genetics) and at the end of the year have nearly five months with no call...I think I might miss it a little.

Three things I've learned today this week
1. Congenital diaphragmatic hernias - are associated with pulmonary hypertension
2. The differential for congenital diaphragmatic hernia is eventration, where the diaphragm is weak, but not truly herniated
3. Hypokalemia can, in and of itself, cause an electrolyte-wasting tubulopathy

So one of my patients was just* diagnosed with cancer. The psychiatrist e-mailed me. The psychiatrist, because we'd thought that all of her symptoms were related to her (overwhelming) anxiety and rushed her out of the hospital.

(*N.B. this post was quarantined for several months, in addition to changing of several possible demographic features to ensure that there is no clear connection to any specific patient)

I had inherited the patient from the previous intern when I came on, which is always hard, because you don't really get your own first impression. My attending had felt really strongly about the psychiatric nature of her symptoms and about rushing her out of the hospital. I wasn't sure I agreed, but I didn't have a strong sense of the patient and my attending was very strong willed. On the second to last day of her admission, I talked on the phone with the psychiatrist and she had said to me: "you know, I'm still not convinced that all of her symptoms are psychiatric" and I'd replied "off the record, I'm not sure either."

But to be fair, the next words I'd said were: "but I am convinced that she has nothing physiologic that is rapidly progressive or threatening her well-being or will benefit from an inpatient admission." And that, even with the retrospectoscope, I completely stand behind. I'm not even convinced, even now, knowing that we're discussing a patient with a metastatic malignancy diagnosed one week later, that any of the symptoms for which she was admitted have anything to do with her cancer. (She got diagnosed after presenting with a totally new symptom a week after discharge)

You hear these horror stories of missed cancer diagnoses, by Horrible-Bad-Doctors and think "how could they not have known." And the answer, at least in this case is two-fold
1. Patients with high levels of anxiety and high levels of somatization bombard you with every complaint that they can think of and every possible diagnosis that they read in the internet and it's hard to see the forest for the trees. You think "well, I can't think of a diagnosis that contains all of those symptoms" and "all of the diagnoses that this patient has suggested don't fit" so you dismiss the entire package. And 99% of the time, that's the right response. But even hypochondriacs and patients who somaticize develop true organic illness, buried among the somatic complaints.
2. The goals of a hospital admission from the point of view of being a doctor are different than the goals of a hospital admission from the point of view of being a patient. As a doctor, a patient should be in the hospital only so long as necessary to establish a safe discharge (in which airway, breathing, circulation and hydration/nutrition can be accomplished.) It's my job in the hospital to make sure that the patient doesn't have anything rapidly progressing that would make them unsafe, but not my job to diagnose every symptom. Diagnosis is largely left to the outpatient realm.

It's still scary. I'm glad someone diagnosed it.

Three more things

This afternoon, after call, I went to a lecture by my department chair on the history of inborn errors of metabolism. He focused on how the discoveries leading up to the modern understanding of inherited genetic diseases revolutionized how humanity thinks of itself. Namely, the idea that inherited characteristics and even more specifically, the mind is governed by biochemical principles. It was a really inspirational, fascinating talk. Anyway, posting post-call, so without further ago: here's what I learned today

1. Neonates generally don't benefit from ventilator rates less than 10 (this only kind of counts -- I totally knew this, but didn't make use of my knowledge at 5:30 AM.)
2. People with PKU who are treated early average a normal IQ but often have subtle cognitive differences, especially decreased executive functioning.
3. Glycogen storage disease type I patients cannot ever mobilize glucose in response to glucagon, but type III patients can if they have been fasting for less than 2 hours.

Bonus: Apparently the phrase "Selling coals to Newcastle" is similar to "Preaching to the choir," because Newcastle exports a lot of coal. However, it's historically inaccurate because lots of people have profited by selling coal to Newcastle. Honestly, to me, it sounds like an Iron Dragon reference. (Selling dragons to Nordkassel?)

Three things I learned today

So I've been doing something new. Actually, it's not quite new - I did it at the very beginning of last year, too. But I've been trying to formally think about three things that I learned in any given day. Often, they're about medicine. Not just because the vast majority of my waking hours are spent physically in the hospital, but also because one of the huge advantages of where I live and where I work is that I have a half-hour walk each way, which is a fantastic time to reflect (and also where I get most of my reading done.)

However, I consolidate new information well by writing. I often write in my Little Black Notebook and over the years have amassed huge amounts of information in my Little Notebooks; however, my handwriting is little even proportional to the Little Notebooks and there's no search function on the Little notebooks, so I thought I would start trying to blog. It has the added bonus of being a form of microblogging that's based on something I already do, which tends to help me overcome my barrier to writing.

For those of you readers not interested in medical science, I'm going to tag these posts 3til to make avoidance easy (no promises that there won't be non-science contained in future posts.)

So without further ado, here are three things that I learned today:
1. Jaundice in newborns can be caused by UTIs. This is especially true of conjugated hyperbilirubinemia and jaundice that starts after 8 days of age.
2. Cori's disease (Type IIIa glycogen storage disease) can cause hypertrophic cardiomyopathy. In retrospect, I could have derived that information from what I already knew about glycogen storage diseases and cardiomyopathy, but I didn't, so there.
3. Many little known things about NEC:
a. usually in the TI or colon
b. not associated with the rate of feed advance OR with the timing of starting feeds
c. not associated with trophics (this is cheating as I totally knew this already and tried to show off on rounds by saying so, but I was "corrected," so I'm including the recorrection.)
d. IS associated with acid blockade