Peds ER in Oakland

Hi All,

This November I did a rotation at Oakland Children’s Hospital in Pediatric Emergency Medicine. It was a really incredible experience!

I drove from San Jose everyday (about 1 hour without traffic, but coming home was always at peak traffic times, so it could take up to 2 hours) and was scheduled almost every day of the month. The commute was tough (got into an accident on my first day), but I really liked being home with my family, so I stuck it out.

The rotation itself was intense–I think any ER rotation will be–we saw traumas, sickle cell crises (the hospital is known for treating this), lacerations, viral/bacterial infections (a lot of these) and asthma exacerbations.

One of the patients I triaged was a teenager with tingling and numbness in her feet and hands. She had difficulty walking too. She had gone to her pediatrician and was told that she couldn’t get an MRI for a few weeks, but her symptoms just kept getting worse, which is why her mom brought her to the ER. It didn’t sound like an infection or Lyme disease… so we did an MRI and ended up finding giant mass on her cervical spine. It was such a heartbreaking experience.

Another patient was really young and had gotten her fingers crushed in a door. She was autistic and this happened at school. The moment I saw her face, my heart melted. She was so good and so quiet, didn’t even cry, even though her fingers were crushed and bleeding. It wasn’t until her mother came (hours later) and she thought it was time to go home (but we didn’t let her leave just yet) that she finally started crying in frustration. Yet another heart breaking experience.

We had two traumas come in around the same time one day. The first was a Black child who was sitting in the back seat of a car without a seat belt. The car hit a semi in front of it and the glass shattered everywhere. The second was a White child who was riding a bike and got hit by a car. This child was wearing a helmet. I remember the parents of both these children rushing into the hospital. The Black child’s mother came in and this little boy kept apologizing to his mother, saying that he had messed up and that it was his fault for not wearing a seat belt. The White child’s mother and father came in together and their son just kept repeating that he was ok. Both families are from Oakland. They may live a few miles apart. But what a stark difference in their experiences, behaviors, and support systems. Why can’t we provide all our children with the same opportunities? With the same knowledge?

We also had cases of non-accidental trauma (child abuse) that shook me to my core. We had several suicidal and depressed children as well. I couldn’t wrap my head around this. One of the patients I was working with had been passed from foster home to foster home and her parents were drug addicts. Many children were malnourished but most were obese, eating what they could, just trying to survive. I grew up with parents who sacrificed everything to raise us, who always (to this day) put us first and it is so unthinkable to me that parents would harm their children. To have it in the back of your head as a provider that maybe a parent isn’t telling you the entire truth is so hard to wrap my head around.

All in all, this experience really brought to light many of the social issues that come with raising children. Honestly, when you are dealt a crappy hand, sometimes all you can do is just try to survive and raise your kids the best you can. But as much as I loved my outpatient third year pediatrics rotation in the small town of Walla Walla which had a lot of loving, supportive, mostly White families focused on raising their children and providing them with opportunities, not every child is getting the love and support that they need and deserve. Sometimes the situation just isn’t great at home. Coming from a single-parent household, I absolutely see the benefits of a middle-class, two parent home (and there are days that I wish I had that). I guess what I am rambling about led me to the conclusion that I am not strong enough to handle pediatrics. I think I went home crying more often than not during this rotation. Kids are more than just their broken arm or their 4-day cold or their cervical mass–they are the epitome of purity–creatures that need love, guidance, patience, and support. It broke my heart when they did not receive these things. And as providers–in every specialty–it’s our job to ensure that the children in our communities are getting those things. It truly takes a village to raise a child–I can absolutely speak to that–I grew up with aunties from our spiritual group driving me home from school everyday, cooking for our family every week, taking us to doctor’s appointments, babysitting my sister, and teaching me how to cook and clean. Without my support system, my village, I wouldn’t have the opportunities I have today.

So for every child that is part of my community, I promise to be part of your village. I promise to stand up for you, to work with your schools to teach you about your health, to work with your parents and to pay as much attention as I can to you and your needs, regardless of what specialty I go into. May you all be loved, supported, and taken care of. May you grow up to be happy, healthy, whole individuals. May you grow to leave this world in a better state than what you found it in. May you do good and great things.

-P

 

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It’s always an emergency around here…

I can’t do shift work. Physically. My body does not understand sleeping during the day or going to bed at 5 am. We were very confused for one full month. Aside from a wacky sleep schedule, this ER rotation was pretty legit and fun. I was surprised. For one full day I thought to myself, I could totally see myself doing this. Then I slept for 12 hours.

Here are some of the fun things I was able to do:

  • Rinse maggots out of a golf-ball sized wound. This made my stomach turn.
  • Manual disimpaction – if you’ve ever gotten your hands on a stool ball you will know what I mean. It is just as gross as it smells. But the patient feels much better even if you just inadvertently disimpacted your stomach.
  • Lumbar puncture on an 8 day old baby – very tricky since they’re wiggly. But ya’ gotta rule out Meningitis, first!
  • LOTS of suturing. Thankfully this is what kept me awake on most of my night shifts. I think my record number was 41 stitches.

These are all that I can remember, since I did this rotation back in August/September. I am glad to not be an ER doc, but get why people go into this field. Pretty cool stuff, but boy are the sleep schedules rough…

“Our lives suck… ” said this 30 year old boyfriend of my patient. I was in the middle of performing an incision and drainage on his girlfriend when he made this statement. The abscess requiring the I&D was a product of repeated heroin injection from using a dirty needle. She would lick her arm “clean” then inject heroin with a previously used or shared needle. Her feet were covered in dirt. Her dentition was poor. She and her boyfriend had been using since they were 15 years old. They were crying. She was crying from the pain and stress of the procedure, him from watching.

We sat and talked for a while about their heroin addiction. They both knew they needed to quit, but every effort they made was deterred by physiologic (withdrawal symptoms) and psychological (hopelessness) barriers coupled with a real lack of resources. I wish I could have told them that the resources are out there and that pain clinics are easy to access, but the exact opposite is true. Methadone clinics are available, but may be difficult to get to. Patients in the area I work in have to travel to neighboring cities for methadone clinics, another real barrier to getting treatment.

“… we live in a tent.” It was raining last night. Keeping the wound clean, ideally a simple task, was a source of stress. No access to clean water, living on a floor of dirt, and relying on a tent roof for protection.

I left wishing them the best and reinforced their desire to quit their addiction.

It probably wasn’t enough.

It’s a wrap! (almost)

Hello All!

Hope you are all doing well! It’s been a while since I’ve posted and have since completed Surgery, ER and OMM! I’m on my final rotation–psychiatry at the State Penitentiary–and it’s going to be interesting, only four more weeks to go!!

Just to recap, surgery was a great rotation, I learned a ton and had a great preceptor. It was AMAZING to help resect a patient’s bowel and anastomose it, make incisions and suture them back up! The challenges were that surgery is sooo physically exhausting; my feet were killing me at the end of every day and the days were really long. I also realized how complex and incredible the human body is and how brilliant surgeons are to know what to cut or bovie. It’s hard work!

OMM was four weeks and was mostly like a family med rotation except that we spent Tuesdays and Thursdays with a fantastic preceptor who spent 4 hours reviewing material and going over techniques. It was like being in OPP lab again but everything came easier since we had learned it at least once before. I really like working with this preceptor twice a week, she was also an attending at a family medicine residency program for years and was able to give us a lot of insight and advice on applications and programs!

ER was four weeks as well and was great. We work 3 shifts/week or whenever our main preceptor is on shift. We do 12 pm- 12 am shifts which allow us to see the most. I got to fix a nursemaids elbow (the family was super happy), stitch up a prisoner’s face who got pummeled at the penitentiary, do OMT on a MVA patient, and learn a ton! It was awesome.

Now that my last rotation is here, I’m really grateful for the time I’ve had in Walla Walla. Our dean is so encouraging and our coordinator is fantastic–so organized! The doctors have been incredible teachers and I can’t express how much I appreciate all our patients and their patience!

So now it’s onto board exams, moving, weddings (Congrats, Jenny!), audition rotations and electives. I have a feeling that in the craziness of it all, I won’t get the chance to blog, so here’s to EDC. Could not have pushed through without the love and support of family and friends!  Wishing everyone an amazing end to an amazing year and luck with the next leg of our journey!

-Priya

 

Rotation #1 Review and Tips

Hi All!

My first rotation has been very interesting! I started in the ER (3 weeks), spent 2 days in Nephrology, and have since been in Internal Medicine (outpatient)! So I’ve got 2 reviews for everyone!

Emergency Medicine:

Working in the ER is tough; you have no idea what’s going to come through the door and the moment someone does come through, it’s GO, GO, GO! I saw MVAs, strokes, seizures, MIs, AKI, fishing hooks in fingers, lacerations, fevers, fractures, muscle strains, pain, wounds, bleeds, infections, and lots more.

  1. SCHEDULE: 12pm-12am shifts with certain preceptors; this allowed me to have several days off depending on when my preceptors where working (I think I worked 10-11 shifts total in 3 weeks, sometimes weekends). Make sure to eat before, have a snack on hand, and arrange for dinner.
  2. CLOTHES: change into hospital scrubs on site.
  3. SHOES: with 12 hour shifts, you need comfortable shoes; I have flat feet and own some heavy, super supportive Dansko shoes–however, my feet would be aching halfway through my shift. I bought a pair of Crocs (without holes) and they have been light and great–they just don’t have as much support. Some of the doctors also recommended Birkies (Birkenstock).
  4. Why it’s AWESOME:
    1. You get to see some really interesting pathology. I saw a patient with Erythema Multiforme (from Terbinafine use) and a patient with Temporal Arteritis.
    2. You get to do a lot! I removed stitches, help with reducing a shoulder dislocation, nail removal (super bloody), catheterizations, blood draws, IV line insertions, give shots! I even did a pelvic exam on a pregnant patient.
    3. In the ER, everything just happens. Literally. Blood work and imaging come back so quickly! It’s amazing. I got to go in for some of the ultrasounds and see the techs at work too.
    4. You get to do some OMM. I did some cervical spine treatments for a few patients after an MVA. However, in some cases the issue is too acute to treat with OMM.
  5. Why it’s TOUGH:
    1. You have to be prepared for ANYTHING. We had a patient come in from the Washington State Penitentiary (with armed guards!) with massive epistaxis–he lost 20% of his total blood volume! At first, I was apprehensive of both the patient (he was in an orange jumpsuit) and of all the blood loss (2 tubs were filled), but as I interacted with him, I was able to let go of my judgement and fear and simply treat him like any other patient.
    2. You have to be ready to do whatever you need to do in order help the patient–including getting out of the way.
    3. It’s difficult with kids–especially because they’re not feeling food, are injured, need to be cath’d, need to get a shot, or need to have their eyes dilated.
    4. You don’t know what’s going to happen to the patient. A lot of the time, the ER physician is simply trying to keep the patient alive. Long term issues or even concrete diagnoses are not always addressed. Everything is very acute and that was very frustrating for me. I wanted to get to the root of certain issues, but in the ER you just need to keep the patient alive and then release, admit, or transfer them.
    5. You don’t have time. You don’t get to really talk to patients and their families or get to know them. I realize that spending time with patients is limited in every setting, but I think getting to know patients is something that’s important to me.
    6. Your heartstrings get tugged on. We had a patient who was transferred to the ER from a nursing home, without any friends or family, because the nursing home knew he was dying. Since he was alone and my preceptor was catching up on some paperwork, I was able to sit with him as he passed. The experience still resonates with me.
  6. RECOMMENDATIONS:
    1. Studying:
      1. Know your ACLS algorithms, treatment for acute issues (like MI, stroke, CHF exacerbation).
      2. Review how to read a chest x-ray and EKG.
        1. CXR mnemonic: ABCDEFG-L (Airways-trachea, bronchi, Bones-ribs, clavicle, pedicles/SPs on vertebral bodies, spaces between vertebral bodies / Breast shadows, Cardiac – silhouette, size, aorta, AP window, pulm art, Diaphragm-costophrenic angles, air underneath, especially on the right as the left can often be stomach bubbles, Esophagus-not usually seen, Free air anywhere, Gunk anywhere, Lungs)
        2. There is no COMAT exam for this rotation.
    2. Brush up on your suture skills before this rotation
      1. Duke’s Suture Skills Course
    3. Get light, comfy, protective shoes
    4. Be mentally prepared for anything!!
    5. Take care of yourself; reflect on what you see and let it go.

Internal Medicine (Outpatient):

Outpatient IM is a totally different world than the ER! You’re in an office setting with scheduled patients and you usually work set hours.

  1. SCHEDULE: 8am-5pm M-F
  2. CLOTHES/SHOES: Professional dress with white coat and comfortable shoes
  3. Why it’s AWESOME:
    1. You get to spend time with patients! You get to know them and you can counsel them on diet, exercise, and smoking cessation. We had a patient with Non-Alcoholic Fatty Liver Disease (NAFLD) and I was able to spend a few minutes with him talking about dietary changes and what to expect if the disease progresses. I couldn’t imagine spending that much time with a patient in the emergency department.
    2. You get to work on your H+P skills. My preceptor is really nice and the patients love him. He enters every patient’s room with me, introduces me and asks if the patient can spare a few minutes to talk to me while he finishes up some paperwork. I then get some time with each patient to complete an H+P, which has really helped me figure out what’s important to ask (any nausea or vomiting with your headache?) and to differentiate lung and heart sounds!
    3. You get to see some really interesting pathology. I saw a patient with argyria (blue man syndrome after years of taking colloidal silver suspension), Marfans, SLE, the aftermath of narcotizing fasciitis, candidates for bariatric surgery, psoriasis, shingles, and more.
    4. You get to do some OMM. You’ll see pregnant patients, patients with back, neck, leg pain, and so much more. My preceptor (who is an MD) asks if I can do some “magic” for these patients and it usually helps!
  4. Why it’s TOUGH:
    1. It’s a juggling act. These patients have many things going on–not just diabetes, hypertension, and hyperlipidemia, but anxiety, OCD, and stress.
    2. There’s always a time crunch. Each appointment is only 15 min long, and you’re seeing anywhere from 18 – 25 patients in a day and there’s still charting to finish!
    3. You’ve got to be up to date! Medications, research, procedures, insurance codes, other requirements are all constantly changing and growing. You’ve got to be on top all this information!
  5. RECOMMENDATIONS:
    1. Check your patient list before
      1. We are able to access our physician’s patient list on EMR, so we can check to see why patients are coming in (this is not always accurate though). If you can do this as well, I’d recommend brushing up on those things for that day.
    2. Know your meds
      1. Psych: There were a lot more patients that I expected who are on various combinations of antidepressants and anti-anxiety drugs, so it’s important to know the side effects and indications for these.
      2. Schedule II and III: Lots of patients come in for pain. They must come in to get their Rx filled every month or so.
    3. Lots of geriatric patients – make sure to speak up when they can’t hear you!
    4. Studying
      1. At our site, we have outpatient and inpatient IM (6 weeks each) and our COMAT exam is at the end of the 12 weeks. My next IM rotation isn’t until 2016. I would recommend going over some common chronic diseases (DM, HTN, thyroid, CAD), medications, and psych diseases.

I hope your Emergency Medicine and Internal Medicine rotations go well and that this long list is helpful!! I had a great time during both! 🙂

-Priya