Tuesday, March 1, 2016

The way it was

Somewhere in the early 1980s.  Attending rounds for pediatric neurology were held 3 days a week in an isolated conference room.  All the patients currently in the hospital would be presented and discussed.  Following this, the team would head out to the wards, intending to have some bedside encounter with the patients, but, ideally, no encounter with the housestaff or a parent.  One of the wards at the time had patients less than a year of age.  One of the several patients had multiple congenital anomalies and another patient had trisomy 21, among other problems.  When we came to the ward, our attending mentor, an eminence grise, stood standing over the bedside of the child with multiple congenital anomalies.  He seemed transfixed in thought.  "What is the sage thinking?" we all wondered.  He then at last turned and asked, "How well is the diagnosis of trisomy 21 established in this patient?"  He had confusion about which of the many patients presented in that far away conference room he was viewing.

As we were about to become third year fellows in pediatric neurology, we met with one of the graduating third year fellows.  Attending rounds for pediatric neurology were held 3 days a week. Any issues regarding admission or management of hospitalized pediatric neurology patients were directed exclusively to the third year fellows.  We asked our graduating colleague, "When do the attendings want to be informed about patient issues?"  We were told, "It depends on how confident you are in what you are doing.  I rarely spoke with the attendings, but my counterpart spoke to them frequently."  Once we were the third year fellows, just starting, a 6 weeks old infant presented with fever, lethargy and seizures resistant to phenobarbital and phenytoin.  There was cerebrospinal fluid pleocytosis.  Pentobarbital coma was initiated.  By the time of the first attending rounds, there was already a plan activated for brain biopsy, which was subsequently performed.  This established a diagnosis of Western equine encephalitis.  For more details, see:  Englund JA, Breningstall GN, Heck LJ, Lazuick JS, Karabatsos N, Calisher CH, Tsai TF. Diagnosis of western equine encephalitis in an infant by brain biopsy. Pediatr Infect Dis. 1986 May-Jun;5(3):382-4.

See:  http://childnervoussystem.blogspot.com/2015/06/anencephaly-way-it-was.html
http://childnervoussystem.blogspot.com/2016/02/medical-training.html

24 comments:

  1. A pediatric neurology fellow came to the floor and handed the hapless intern a list of blood, urine and CSF studies that were desired on a patient. When the intern had the temerity to ask, "Why are we doing such and such studies?", the fellow responded, "Well, do you have a diagnosis?"

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  2. The senior pediatric neurologist at another institution than the above was known to ask as he stood at an infant's bedside, "Is this child dysmorphic or just from the neighborhood?"

    The same eminence grise, when a fundamentalist adolescent female was admitted, would always ask, "Has she had a pregnancy test?"

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  3. An eminent endocrinologist was ward attending. One of his own patients, a very obese adolescent female was admitted for evaluation of hypothermia (basal temperature around 94F) and bradycardia. He desired CSF studies on this patient. Since there was general concession that an LP on this patient might be challenging, I, the intern, was directed to speak to neurosurgery. The neurosurgery fellow, probably reluctantly, said he would observe me do an LP. Thanks but no thanks; the challenge was quite sufficient without a critical audience. Fortunately, the LP went surprisingly well and CSF was obtained. As I recollect some of the CSF had to be fast frozen for some esoteric test. Later, the attending came by and discovered esoteric test #2 which he had desired and also required fast frozen CSF had not been ordered. Neither I nor my senior resident had known of this. The attending was livid and a rage episode ensued, with screaming and spittle flying (see http://childnervoussystem.blogspot.com/2015/12/psychopathic-spectrum-disorder.html). The attending left the floor. Later he returned, all sweetness and light, and said, with a smile on his face, "They split the specimen."

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  4. A patient was admitted with hepatitis of undetermined cause, which eventually resulted in his death. He was followed by the GI service. That meant, of course, that the parents interacted with fellows but never saw an attending. At one time, when I was intern (the same month as the preceding entry), the parents told me, "I know we are getting great care here and we are so happy to be under the care of Dr. Big (the world famous attending), but do you think it would be possible for us to meet him?" I spoke to the fellows, two females, known as Dr. Big's Angels, who thought possibly this could be arranged. The day following the fateful meeting, the parents said, "We met Dr. Big and we know he is oh so eminent, but he is very strange."

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  5. A senior pediatric resident intending to pursue a GI fellowship with Dr. Big (see above) was poised to do her first liver biopsy under the direction of Dr. Big. Dr. Big pushed up the liver and the resident then jabbed the biopsy needle. "Ow!", said Dr. Big after the needle passed through the liver and skin into the palm of his hand.

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  6. Long after I had finished my training, an elevator opened and Dr. Big was inside, staring fixedly forwards. I got in and rode numerous floors with only Dr. Big. I am quite sure if his galvanic skin response had been measured that there would have been no change on my entering the elevator. He remained in his transfixed state until I reached my floor.

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  7. From a colleague: My favorite was an eminent adult strokologist who was rounding on an encephalopathic homeless alcoholic. He turned to the gaggle of docklings and said “now this is the type of person whom you would want to strap to the hood of your car and drive through a carwash.”

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  8. A neonatology attending was talking with a pediatric neurology fellow about a cranial CT done on one of the patients (this was pre-MRI). A radiologist had read the study as normal. The fellow responded, "Well, Eminence Grise(the first one from the post) says it is abnormal!" The neonatologist calmly replied, "Even a great man can be wrong."

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  9. There were two pediatric surgeons. The senior neonatologist, for some reason unknown to most of us, detested one of them. When the surgeon he liked was unavailable, the neonatologist would go through extraordinary gyrations to medically maintain the patient until his favored surgeon was available. Of course, there were times when, with utmost reluctance, he had to let the detested surgeon operate.

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  10. The favored surgeon in the above comment was the fastest draw in the region and known as an extraordinary surgeon. The other surgeon had a reputation for being slow. This probably played into the senior neonatologist's detestation. One patient was operated on by Dr. Quick Draw for a leg mass. In the blink of an eye, the leg mass was removed, along with the segment of the femoral nerve which passed through it.

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  11. Starting as an intern, I was first assigned to the ward in the post occupied by infants less than one year of age. One had end-stage biliary atresia, another had severe congenital hydrocephalus, another had congenital nephrotic syndrome, another had a single atrium and ventricle, etc. One of my fellow starting interns said, "I have heard of tertiary referral centers, but this place is quaternary!"

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  12. From a colleague: I had an attending in residency say at a patient’s bedside, to the America-Asian resident, “I can’t tell if this child is dysmorphic or just Asian." Ultimately we decided she was both.

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  13. It was the first day on service in the NICU for a group of interns. After rounds on all the patients with the attending neonatologist, the interns sallied forth to do their day's tasks on the patients assigned to them. Awaiting them were the NICU nurses, who were highly competent and capable, in contrast to the interns who were neither, and who were quite aware of the discrepancy between themselves and the starting interns. My fellow second year resident on the NICU service with me at the time said, "It's like watching the sheep go out to the wolves."

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  14. From another colleague: One poor devil was a frequent flyer because of DTs. My co-resident wore a beard and bore a resemblance to every portrait of Jesus that I have ever seen. The patient awoke just as my co-resident and I arrived, our bodies haloed by the light beaming through the window behind us. The man was convinced that he had died. He was not too distraught about it, because he thought my co-resident was Jesus, so he assumed that he had gone to heaven despite what he considered to be a wicked life.

    We quickly assured him that he had not died. To this day, my co-resident is known to his former resident mates as “He-sus.”

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  15. When we went to outlying regions to pick up neonates from local hospitals to transfer to the NICU, a moonlighting resident would go along with a transport nurse. On one such expedition, the plane which was originally supposed to take us had problems, so quickly an alternative plane was prepared. On this flight, there was also a pregnant nurse, who was training to be a transport nurse. The pregnant nurse was somewhat queasy about the whole undertaking from the beginning. After the delay and confusion involved in getting the second plane outfitted, we were ready to fly. These were twin engine small planes which were exceedingly noisy and shaky. As we took off. there came a shriek from the nurse in training. Her seat in the hasty outfitting had been bolted at the rear but not at the front, causing it to tilt backwards as we took off. The pilot peered back into the cabin and saw what the problem was. When we reached a cruising altitude, he placed the plane on autopilot and, leaving behind an empty cockpit, came with a tool to bolt down the remainder of the seat. It seems like the fright the nurse in training experienced on the takeoff did not approach the fright she experienced seeing the pilot walking back towards her and leaving the empty cockpit.

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  16. The senior pediatric resident referred to above (3/5/16 7:14 pm) came out of a patient's room one morning, hollering at my fellow intern, "Intern! Intern! Didn't you hear a murmur on this patient?" My fellow intern, who obviously had had an exhausting night on call and looked every bit of it, said, "Oh, resident, I listened to so many hearts last night I don't remember what I heard on anybody."

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  17. As a senior medical student, I hung around the pediatric neurology clinic when I was able to do so. The pediatric neurologist, then in his first post-fellowship position but later to become an eminent figure in pediatric neurology, was speaking to the mother of a child with Sotos syndrome. He asked the mother, "You were told your child has Sotos syndrome, but were you told what that meant?" "Well, no." the mother replied. "Your child will be happy and sad like other children, but when it comes to reading or math your child will have real difficulties." "Oh that's all right!" the mother replied. "His father's none too smart hisself."

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  18. A child had an unexplained acquired encephalopathy. The attending pediatric neurologist was determined to solve this puzzle. "Do you have any pets?" he asked the mother. "We had a dog, but my husband shot him." Now, this was getting exciting, with visions of Old Yeller and the slobberin' fits. "Was the dog ill?" "Oh no," the mother replied. "My husband hates dogs. Whenever we get one, he tolerates it for a while, but then it gets on his nerves and he shoots it."

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  19. I wandered into the hospital on a Sunday to do rounds. A family was pacing about and looking perplexed. "Can I help you?" "We're here for the cardiology clinic." I responded, "The clinics don't operate on Sundays." "But they told us to come back in a year!"

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  20. A parent telephoned when I was on call. The parent had a child with epilepsy and a dog with epilepsy. That morning the child's and the dog's medication had inadvertently been switched.

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  21. An infant who had been hospitalized 6 weeks earlier returned for a clinic visit. The was a band-aid over the lumbar spine. "Did he have another lumbar puncture?" "No. No one told us we could take the band-aid off."

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  22. When I was a medical student, there was an adult patient in psychiatry with delirium tremens who needed an LP. The resident sought his consent for the procedure. Although it was unclear whether the patient knew what planet he was on, he was willing to sign the consent. The resident held the consent form as the patient held a pen with his arm flailing nowhere near the paper. Eventually, the resident maneuvered the paper to where the pen and paper made some form of contact and informed consent was certified.

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  23. For reasons I cannot recollect, I did a pathology elective during my residency. The pathologist was doing an autopsy on a neonate. One of my fellow residents[see 3/7/16 8:42 am comment above], on whose watch the neonate has passed on, came storming into the autopsy suite, saying, "Is that my baby?" The pathologist with a horrified expression looked up and said, "Are you the father?"

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  24. Another eminence grise, this one a pediatric hematologist/oncologist undertook to show an understudy how to convey a diagnosis to a patient. The patient was an adolescent female and the diagnosis was some awful malignancy. The eminence grise said, "This is bad. Sometimes when people say 'bad', they really mean 'good'. But this is not like that; it's really bad."

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