Though it seems so long ago, the month and a half I spent on the interview trail is one of the most interesting times of my life. This high stress environment did not suit me, believe me. But this time really did teach me that you CAN get used to anything. By no means is this an exhaustive list, and it does not serve as a strict blow by blow. However, these are some of the small quirks I wish I had known during this time.
1. Schedule: The month of September/October can be very exciting! I was definitely glued to my smart phone, pulse quickening after each and every buzz indicating I got a new email requesting my presence during an interview. Harness your chi, and welcome your inner anal retentive med-student self, because you have to remember that certain programs only interview during certain days, while others interview daily. Keep your iPhone with the calendar or a small pocket calendar handy at all times. If your top choices only interview during certain days, "reserve" those times until you hear from them (but also be realistic and don't hold your breath forever).
2. Respond to email requests in a timely fashion and know that the program coordinator or program assistant is going to be an incredible lifeline. Be nice to them because they can give your the time to get your foot in the door. Especially when certain dates fall through (and they will!), having these people on your side is great because they are more willing to work with you.
3. They say this time and time again, but schedule your top choices in the middle of your interview. Have one or two practice interviews first in programs you don't particularly love. This gives you some semblance of confidence due to repetition, and it gives you a sense of comparison that can generate questions during the dreaded, "do you have any more questions?" :::blank stare::: moments.
4. Also, the interview trail is expensive! I was definitely spoiled applying in Family Medicine because most of my hotel stays were paid for, as well as most of my meals while I was in the city. I don't know much about other specialties, but make sure you save up some loan money to make this happen. Plane tickets require some shopping around. And most of the time, I opted to drive to a lot of my interviews, to save some money. During what I fondly call my "Tour de Florida", I spent $650 in gas money. Awesome. Just be prepared.
5. (4b) This might be pretty obvious, but try to bunch your interviews close together so you can avoid too many flights. Rent a car! Or drive in spurts. I used Tampa/Orlando as a home base instead of Pensacola because flights out of there were much cheaper and the central location was much more conducive to driving to my different interviews. Try to find a hub from which you can spoke out from, or do what some other people did and get a one way flight from your furthest destination and drive with a rental car back to your point of origin.
6.(4c) This is probably not a big deal for people who have nice, brand new, reliable cars. But I've been driving my Civic since high school and it is nearing its last breath. Pushing the car to do what I asked it to required some planning. First the essentials: get an oil change, change out the tires, get new windshield wipers, check the fluids in your car, make sure the spare tire was accessible, do minor repairs, make sure that you have AAA or some other road side assistance. Then, the extras: invest in a GPS if you don't already have one, plug in the old iPod with some tunes or some audiobooks to help the time pass.
7. Dress: I always chose to wear a traditional black suit. And ladies, perhaps one of the biggest challenges is finding some good looking comfy shoes. You will tour hospitals and walk a lot. The last thing you want is to be distracted by ill choice footwear.
8. Residency dinners are great, if the program offers them. They are usually scheduled the night before the interview and it gives you a chance to talk to the residents and ask them questions. It is also a good time to size up these people to see if you would want to work with them, if their personalities jive with yours, etc. Use this time wisely because some programs give residents equal vote and all programs rely heavily on their impressions. Just some etiquette issues: try not to order the most expensive thing on the menu and use your judgement when ordering any wine or alcohol (or just don't do it). Give medicine its just due, but the residents are also trying to sell you their city so ask about what they like to do for fun, what makes this program unique being in this city, etc. Remember that though it may seem intimidating that these residents are (gasp) doctors, they are only a few years removed from where you are sitting. Some of the best residency dinners I went on eventually drifted towards topics of Fantasy Football (which is ok by me).
9. Know your application. They WILL ask you about it. Don't be dishonest. Don't overly embellish. Be genuine. These people meet a TON of people during the interview season. Their BS meter is honed and primed. Be sure to have some questions ready specific to the program. And lastly, be courteous, but let your personality peek through. There is no sense being a polished non-version of yourself. You have to find a program that suits you and they have to find a candidate that suits them. It is like speed dating, so put your best foot forward but don't forget to be yourself.
10. Write thank you notes. I had a stock email for the program director, attendings, residents, chief residents, and program coordinators. I just filled in parts that were unique to our conversation/experience. Write notes for yourself. I made a spread sheet that had all the important facts that differentiated one program vs another. It will definitely be helpful when all of the interviews start running into each other!
That's all for now, but I'm sure there are more that I haven't covered. I hope this is a good start!
Friday, May 11, 2012
Wednesday, May 9, 2012
Insurgent by Veronica Roth
I have really enjoyed having the time to read fun, fiction books during the past few weeks.
On May 1st, Veronica Roth's sequel to Divergent, titled Insurgent, came out, and I was extremely excited about it! I find myself lucky, having finished the first book just days prior to the sequel release, and not having to wait a long time to read Insurgent. The current buzz on the book is that Roth did not opt to do a tremendous amount of summarization of the previous novel.
Of course it is difficult to write a book review for a sequel without divulging too much about the plot, so there are some spoilers. You have been warned.
First, the strengths: Tris has lived through a harrowing experience on her Initiation Day, including deaths of her parents and of one of her friends (covered in Divergent). I felt that her hesitance around guns, the persistence of her nightmares, and the way she made wanton decisions that put herself in risky situations, made her pain very real, very pervasive, and very natural. Despite all the activity that was going on around her, Tris had to continue to force her way to work through these fears and deaths and incorporate them into her world view. Instead of haunting her, these events eventually drove her actions and goals.
We also get a chance to view the different factions and the different capacities in which they work. Since the first book focused on Abignation and Dauntless (and a little bit of Erudite), we at least get to see the inner workings of Amity and Candor. Proving herself truly Divergent, it makes sense that Tris can make attempts to blend in, but never truly does fit in.
Her relationship with Four flourishes, and we find him to be a far more complex character with many more layers than he initially let on. And the torture. And the betrayal. And the twist! It has been years since I got full-body goosebumps at the end of reading a novel (yes it was that good!)
Then the weaknesses: Tris has a lot of talent, instinct, and natural prowess to protect and act as she is brave and self-less. But she sure does need some rescuing! Roth makes a point to illustrate many situations that are almost impossible to get out of, surely to build suspense and to make the book the page-turner that it is, but it seems like Four is Tris's version of a savior over and over again. Yes, it is a romance. Yes, it is an illustrative tool used to show that Four would do anything for her, but I grow tired of it. It would be nice to have a woman that doesn't need rescuing, even if it is just in YA fiction.
The verdict is that this is an amazing book, with no hints at a sophomore slump. I anxiously wait for the the third book in the series, and believe that Roth is just getting started!
On May 1st, Veronica Roth's sequel to Divergent, titled Insurgent, came out, and I was extremely excited about it! I find myself lucky, having finished the first book just days prior to the sequel release, and not having to wait a long time to read Insurgent. The current buzz on the book is that Roth did not opt to do a tremendous amount of summarization of the previous novel.
Of course it is difficult to write a book review for a sequel without divulging too much about the plot, so there are some spoilers. You have been warned.
First, the strengths: Tris has lived through a harrowing experience on her Initiation Day, including deaths of her parents and of one of her friends (covered in Divergent). I felt that her hesitance around guns, the persistence of her nightmares, and the way she made wanton decisions that put herself in risky situations, made her pain very real, very pervasive, and very natural. Despite all the activity that was going on around her, Tris had to continue to force her way to work through these fears and deaths and incorporate them into her world view. Instead of haunting her, these events eventually drove her actions and goals.
We also get a chance to view the different factions and the different capacities in which they work. Since the first book focused on Abignation and Dauntless (and a little bit of Erudite), we at least get to see the inner workings of Amity and Candor. Proving herself truly Divergent, it makes sense that Tris can make attempts to blend in, but never truly does fit in.
Her relationship with Four flourishes, and we find him to be a far more complex character with many more layers than he initially let on. And the torture. And the betrayal. And the twist! It has been years since I got full-body goosebumps at the end of reading a novel (yes it was that good!)
Then the weaknesses: Tris has a lot of talent, instinct, and natural prowess to protect and act as she is brave and self-less. But she sure does need some rescuing! Roth makes a point to illustrate many situations that are almost impossible to get out of, surely to build suspense and to make the book the page-turner that it is, but it seems like Four is Tris's version of a savior over and over again. Yes, it is a romance. Yes, it is an illustrative tool used to show that Four would do anything for her, but I grow tired of it. It would be nice to have a woman that doesn't need rescuing, even if it is just in YA fiction.
The verdict is that this is an amazing book, with no hints at a sophomore slump. I anxiously wait for the the third book in the series, and believe that Roth is just getting started!
The Archetypal Coming of Age Story
This is something I wrote at the end of my first year of medical school, but I never finished. It makes sense though, that I was able to put an ending to it, now that I can reflect back to the experience.
The Archetypal Coming of Age Story
The Archetypal Coming of Age Story
Tuesday, May 8, 2012
Pinakbet
Pinakbet is a Fillipino dish that can be broken down by a few different parts. It has a base of meat with veggies in a soup. It is similar to a gumbo, minus the tomato sauce and seafood.
The more I cook some Filipino food, the more I recognize a pattern. Most dishes start with sautéing a trifecta of
garlic, onion, and ginger. In certain circumstances, like this one, it includes tomatoes. Then, the mixture continues to cook by adding some meat, in this case, cubed pork, until it is browned.
It is seasoned with the same shrimp paste we used in the other recipes called bagoong.
The result is a delectable concoction.
Ingredients:
4 cloves of garlic, crushed and minced
1/2 sweet onion, chopped
2 tablespoons of ginger, crushed and minced
1 medium tomato, sliced in cubes
1.5 lbs pork, cubed
1 cup Green beans
1 cup Okra
1 cup Eggplant
1 cup yellow squash
3 tablespoons soy sauce
1 tablespoon bagoong
2-3 cups of water
Instructions:
1. First, prepare the meat by cutting it in cubes and sprinkle meat tenderizer and set aside in the refrigerator for about 30 minutes.
2. Sauté garlic, onion, and ginger until browned. Add tomatoes until wilted.
3. Add meat until browned, about 15 minutes.
4. Add soy sauce to season the meat.
5. Pour water over browned meat. Allow this to simmer. Then add the bagoong.
6. Add squash and wait 5 minutes before adding in the rest of the veggies.
7. Simmer another 15 minutes until the vegetables are cooked.
Enjoy this with some white rice!
The more I cook some Filipino food, the more I recognize a pattern. Most dishes start with sautéing a trifecta of
garlic, onion, and ginger. In certain circumstances, like this one, it includes tomatoes. Then, the mixture continues to cook by adding some meat, in this case, cubed pork, until it is browned.
It is seasoned with the same shrimp paste we used in the other recipes called bagoong.
The result is a delectable concoction.
Ingredients:
4 cloves of garlic, crushed and minced
1/2 sweet onion, chopped
2 tablespoons of ginger, crushed and minced
1 medium tomato, sliced in cubes
1.5 lbs pork, cubed
1 cup Green beans
1 cup Okra
1 cup Eggplant
1 cup yellow squash
3 tablespoons soy sauce
1 tablespoon bagoong
2-3 cups of water
Instructions:
1. First, prepare the meat by cutting it in cubes and sprinkle meat tenderizer and set aside in the refrigerator for about 30 minutes.
2. Sauté garlic, onion, and ginger until browned. Add tomatoes until wilted.
3. Add meat until browned, about 15 minutes.
4. Add soy sauce to season the meat.
5. Pour water over browned meat. Allow this to simmer. Then add the bagoong.
6. Add squash and wait 5 minutes before adding in the rest of the veggies.
7. Simmer another 15 minutes until the vegetables are cooked.
Enjoy this with some white rice!
Friday, May 4, 2012
Adobo
Adobo
(May 3, 2012)
Introduction:
In my house, this dish has always been a staple. Adobo, much like the Spanish-type seasoning, has a very strong garlic base mixed with a tang of vinegar and soy sauce. I was a kid of the 90s, and along with Teenage Mutant Ninja Turtles and Capri Sun, I grew up watching cheesy paid advertisements for cooking devices that you "set it and forget it". That last sentence might sound like a serious tirade, but in reality, that is what I view this dish to be like. It was one of the first meals I learned how to make by myself, and it is so versatile and essentially idiot-proof. Of course, there are many different takes on this classic, and even in my family, there a three different versions going around. My mother likes to cook her adobo with chicken, and after it has mostly cooked and simmered in the brine I will talk about in detail later, she chooses to fry the pieces of chicken in a separate frying pan to give the chicken meat a slightly golden brown color and crispy consistency. My dad, however, like to make his with pork, and prefers to add potatoes in the mix. Again, these are just slight variations to the original... a little flair, if you will.
I prefer my adobo as classic and plain as possible, with only one slight variation. You will find that it is also the easiest of versions to pull off (partly because I'm lazy, and partly because it is delicious in its simplicity). As with most Filipino dishes, it is frequently served over white rice. Enjoy!
Ingredients:
3 lbs pork with skin, cubed
1 cup soy sauce
1 cup vinegar
5 cloves of garlic, crushed and minced
1/2 sweet onion, sliced
1 tablespoon pepper corns
3 pieces of bay leaves
1 tablespoon sugar
Instructions:
1. First, prepare the pork by sprinkling it with some meat tenderizer and setting it aside in the refrigerator for 30 mins-1 hour.
2. In a large pot, combine all ingredients (pork, soy sauce, vinegar, garlic, onion, pepper corns, bay leaf) except sugar. Make sure that the pork is fully coated with the brine. Remember that the soy sauce and vinegar are in a 1:1 ratio, so if you need to add more, just make sure that they are in equal parts.
(May 3, 2012)
Introduction:
In my house, this dish has always been a staple. Adobo, much like the Spanish-type seasoning, has a very strong garlic base mixed with a tang of vinegar and soy sauce. I was a kid of the 90s, and along with Teenage Mutant Ninja Turtles and Capri Sun, I grew up watching cheesy paid advertisements for cooking devices that you "set it and forget it". That last sentence might sound like a serious tirade, but in reality, that is what I view this dish to be like. It was one of the first meals I learned how to make by myself, and it is so versatile and essentially idiot-proof. Of course, there are many different takes on this classic, and even in my family, there a three different versions going around. My mother likes to cook her adobo with chicken, and after it has mostly cooked and simmered in the brine I will talk about in detail later, she chooses to fry the pieces of chicken in a separate frying pan to give the chicken meat a slightly golden brown color and crispy consistency. My dad, however, like to make his with pork, and prefers to add potatoes in the mix. Again, these are just slight variations to the original... a little flair, if you will.
I prefer my adobo as classic and plain as possible, with only one slight variation. You will find that it is also the easiest of versions to pull off (partly because I'm lazy, and partly because it is delicious in its simplicity). As with most Filipino dishes, it is frequently served over white rice. Enjoy!
Ingredients:
3 lbs pork with skin, cubed
1 cup soy sauce
1 cup vinegar
5 cloves of garlic, crushed and minced
1/2 sweet onion, sliced
1 tablespoon pepper corns
3 pieces of bay leaves
1 tablespoon sugar
Instructions:
1. First, prepare the pork by sprinkling it with some meat tenderizer and setting it aside in the refrigerator for 30 mins-1 hour.
2. In a large pot, combine all ingredients (pork, soy sauce, vinegar, garlic, onion, pepper corns, bay leaf) except sugar. Make sure that the pork is fully coated with the brine. Remember that the soy sauce and vinegar are in a 1:1 ratio, so if you need to add more, just make sure that they are in equal parts.
3. Heat covered in med-high heat for about 30-45 minutes, stirring occasionally. You will find that the pork will release quite a bit of fat as it cooks (You can choose to skim this off as a healthier option) meanwhile, the soy sauce and vinegar will thicken as well.
4. Cook thoroughly until the meat is no longer pink. Minutes before you take it off the heat, sprinkle one tablespoon of sugar and mix thoroughly. This will give the adobo some added sweetness and will allow some mild caramelization on top of the meat.
Again, this meal is best served over white rice. Enjoy!
Wednesday, May 2, 2012
Binagoongan
Binagoongan (Shrimp paste)
(May 2, 2012)
Introduction: Binagoongan (bee-na-go-ong-ngan) may be a difficult word to say, but that's okay because your taste buds will be very busy anyway. The base of this dish is "Bagoong" or salted shrimp paste that has been fermented. Bagooong has different varieties and can be made out of shrimp (bagoong alamang) or fish (bagoong isda). Traditionally, bagoong can be used as a condiment or, as in this dish, part of the sauce base. Part of the fermenting process also yields Patis (fish sauce), which I have used in previous recipes.
(May 2, 2012)
Introduction: Binagoongan (bee-na-go-ong-ngan) may be a difficult word to say, but that's okay because your taste buds will be very busy anyway. The base of this dish is "Bagoong" or salted shrimp paste that has been fermented. Bagooong has different varieties and can be made out of shrimp (bagoong alamang) or fish (bagoong isda). Traditionally, bagoong can be used as a condiment or, as in this dish, part of the sauce base. Part of the fermenting process also yields Patis (fish sauce), which I have used in previous recipes.
(Photo credit from Wikipedia)
Ingredients:
3 lbs of pork, cubed
4 cloves garlic, crushed and minced
1/2 onion, sliced
2 tablespoons ginger, crushed and minced
1 can coconut milk
1/2 cup water
1 bullion cube
salt and pepper
3 tablespoons bagoong alamang (shrimp sauce paste)
green beans
green onions copped
optional: green chile pepper
Instructions:
1. Prepare the meat by cutting the pork into 1-inch cubes. A good way to ensure the meat is tender is to sprinkle some meat tenderizer and let sit in the refrigerator for about 30 mins-1 hour.
2. Saute ginger, garlic, and onion until browned and wilted.
3. Add pork and cook on med-high heat until browned. Add water and allow to simmer for about 10 minutes. Add bullion cube, salt (if needed) and pepper.
4. Add 1/2 can of coconut milk and continue to simmer. Mix in bagoong thoroughly. Continue to simmer for about 10 minutes.
5. Combine green beans, green onions, and optional green chile pepper. Heat covered for another 10 minutes.
Some tips: Remember that the bagoong is a very salty mixture to begin with, so use caution with adding more salt!
This is best served over white rice. Enjoy!
Monday, April 30, 2012
New Posts
New posts will be copied as new blog entry on the main home page. However they will be tagged accordingly under "labels" and will be reposted under the appropriate heading.
Just an update: I have posted new photos under the Photography tab and new dishes under the Recipes tab.
I have also added Pinterest radio buttons for easy pinning!
That is all for now!
Just an update: I have posted new photos under the Photography tab and new dishes under the Recipes tab.
I have also added Pinterest radio buttons for easy pinning!
That is all for now!
I pick you, PICU
This entry has been backdated from September 7th, 2011
It has only been a week and a half into my PICU experience and I am already regretting it. not because i hate it, or because it isn't fun. but because i could see myself doing it. In the first 5 days, i have seen the most amazing kids, the most heartfelt stories, the most heartbreaking tragedies....
~*~
The first kid I followed is a boy named "A. Knievel", a 13 year old male who dislocated his left knee posteriorly while doing a stunt on his motocross bike. He then fell, with the bike landing on his leg, suffering the following injuries:
- a popliteal laceration, later repaired with a femoral popliteal bypass, with a right saphenous vein autograft.
- a proximal mildly displaced salter harris type II tibial fracture, repaired with pins and screws
- a distal non displaced tibial fracture, also repaired with pins
- a four compartment fasciotomy, with rentry and wound vac dressing one week later
- rhabdomyalysis, with a total creatinine kinase level of 17000, but negative for urine myoglobin
- Acute renal injury, secondary to the rhabdo, post-op administration of ketorlac, and vancomycin (with a trough >30)
- positive wound cultures to acinetobacter
Why did he stick out in my mind? i saw him every day, slowly progressing with each passing day towards recovery. He has fantastic family support, and even being a teenager, who is used to having some interesting choice of hobbies, he still had a great smile (when his pain was controlled and while he was flirting with the nurses). And i diagnosed his acute renal injury (thank you to my 2 month stint following nephrologists)
what lessons did i learn from him? First and foremost, communication, even between specialties is paramount to ensuring patient well being. He was kept on the ICU floor for long, and perhaps experienced more pain than was necessary because one surgeon chose not to inspect a previous fasciotomy (on the same leg, mind you) simply because the original fasciotomy was not his doing.
He was transfered out of the ICU to a step down unit today. i'm glad i got to see him happy.
~*~
Baby O, a 9 week old baby that was found by his mom faced down on a blanket, unconscious with clear epistaxis in the middle of the night. he was brought to an outside hospital where he was rescucitated with numerous rounds of fluid boluses, along with three administrations of epinephrine. He was hemodynamically stabilized, rushed via lifeflight to sacred heart, and then was admitted on the PICU service. A new trach was supposed to be put in, and while he was being worked on, he decompensated and once again started to crash. Numerous fluid boluses and a couple more rounds of epi later, and again, he was hemodynamically stable, albeit critical. EEG showed no brain waves. Blood gases showed an increased lactic acid and a ph of 6.8. He was in DIC, showing coagulopathy, with blood found in his urine, in his trach, and his nasopharynx. he had a significant pneumothorax, and i got to assist with putting in his chest tube. blood cultures and sputum culture from the chest tube showed enterobacter. all of his organs seemed to be shutting down, but his heart kept on beating...
So the story thickens... mom is a 14 year old girl, and dad is 17. Grandmother is the primary care giver to the patient and his mother, who is a pediatrics patient herself! there are rumors of co-bedding as well.
Being in that room full of people, being told that the youngest and most fragile member of their family won't make it was really difficult. hearing words like, "he will be in heaven", and "end his suffering" have only been applied to adults in my experience.
After being with the attending while that happened, i excused myself to go to the bathroom to cry.
He passed the following morning.
~*~
Two year old B.H. was happily playing in his mother's house when for a second, he was unattended playing on top of the stairs with a baby gate. Mom heard a crash and a tumble and saw him rolling down the stairs. he acted hurt momentarily, but then continued to play, but his activity level waned as the night progressed. the following morning (sunday), mom noticed that he was unable to climb up on the couch and grasp his water cup. alarmed, he was brough to the ED in an outside hospital where a ct was performed and read as a negative study. He was sent home with some decadron and nsaids and was told to follow up with his Pediatrician in 48 hours. As mom came in to see the pediatrician (tuesday), the pediatrician instructed the mom to return if he did not get any better or if symptoms worsen. and worsen they did. mom states that appeared to be less able to move his lower extremities. on Thursday, mom brought him back to the Pediatrician who instructed them to get a repeat ct in the hospital. The pediatrician got on the phone and called a radiologist to do a repeat read. and that's when another radiologist (apart from the first one who read the study negatively) states that there was indeed a lesion seen in the c2-c5 area.
the pediatrician sent EMS to the pick up the child from the home and was brought to the PICU.
he progressively became more flaccid and is today thought to be a quadroplegic. He underwent a laminectomy and myelomectomy on sunday.
palliative care is consulted. He was transferred to Atlanta for rehab after 15 days of PICU care.
His life is not in danger but forever changed. only time will tell if he will regain function again.
~*~
A 14 year old girl named F.W. has a history of seizures and was brought to the PICU unconscious after a near drowning. History suggests that she was at her grandmother's house, swimming after school, and although she had very close supervision during most of the afternoon her grandmother went inside for a few minutes to use the bathroom. Her grandmother then found her face down and unresponsive. Being elderly herself, she had quite the difficulty pulling her out of the pool.
F.W. is also involved in a long, drawn out custody case. She was currently living with her father and step mother, all the while, mom is fighting a court battle to get her back. Of course blame was thrown all around and DCF was contacted on the case. Mom was in court all day, requesting time to see the judge for a reversal of the custody granted to father and step-mom.
Meanwhile, F's heart is beating strong, she is on a ventilator, and an EEG proved her brain to be damaged due to a lack of oxigenation for an extended period of time.
It took a very strong and kind Peds Intensivist to intervene in this situation and say to Mom: "You can fight this in court all day but you will only get so much time to say goodbye to your child".
After both parents were able to reconcile some of their differences, they made the joint decision to give F's organs for donation. It was an incredible process.... the guilt and sorrow melted into purposeful action with the knowledge that their daughter can give a gift of life to several children. It is an incredible gift, and as F's step mom said, this is something F would have wanted. Her lungs went to a child in gainesville, her liver to a child in south carolina, her heart to atlanta... and the list goes on.
Perhaps the most difficult part of F's story is that she was a healthy, happy teenage girl prior to her accident (much in the same way that my healthy, happy teenage little sister is). And that is why her story really hit close to home. I I pray daily that my sister remains safe, but life really can change in an instant. F's story is testament to that.
~*~
that is it for now. that took alot to rehash all of it.
It has only been a week and a half into my PICU experience and I am already regretting it. not because i hate it, or because it isn't fun. but because i could see myself doing it. In the first 5 days, i have seen the most amazing kids, the most heartfelt stories, the most heartbreaking tragedies....
~*~
The first kid I followed is a boy named "A. Knievel", a 13 year old male who dislocated his left knee posteriorly while doing a stunt on his motocross bike. He then fell, with the bike landing on his leg, suffering the following injuries:
- a popliteal laceration, later repaired with a femoral popliteal bypass, with a right saphenous vein autograft.
- a proximal mildly displaced salter harris type II tibial fracture, repaired with pins and screws
- a distal non displaced tibial fracture, also repaired with pins
- a four compartment fasciotomy, with rentry and wound vac dressing one week later
- rhabdomyalysis, with a total creatinine kinase level of 17000, but negative for urine myoglobin
- Acute renal injury, secondary to the rhabdo, post-op administration of ketorlac, and vancomycin (with a trough >30)
- positive wound cultures to acinetobacter
Why did he stick out in my mind? i saw him every day, slowly progressing with each passing day towards recovery. He has fantastic family support, and even being a teenager, who is used to having some interesting choice of hobbies, he still had a great smile (when his pain was controlled and while he was flirting with the nurses). And i diagnosed his acute renal injury (thank you to my 2 month stint following nephrologists)
what lessons did i learn from him? First and foremost, communication, even between specialties is paramount to ensuring patient well being. He was kept on the ICU floor for long, and perhaps experienced more pain than was necessary because one surgeon chose not to inspect a previous fasciotomy (on the same leg, mind you) simply because the original fasciotomy was not his doing.
He was transfered out of the ICU to a step down unit today. i'm glad i got to see him happy.
~*~
Baby O, a 9 week old baby that was found by his mom faced down on a blanket, unconscious with clear epistaxis in the middle of the night. he was brought to an outside hospital where he was rescucitated with numerous rounds of fluid boluses, along with three administrations of epinephrine. He was hemodynamically stabilized, rushed via lifeflight to sacred heart, and then was admitted on the PICU service. A new trach was supposed to be put in, and while he was being worked on, he decompensated and once again started to crash. Numerous fluid boluses and a couple more rounds of epi later, and again, he was hemodynamically stable, albeit critical. EEG showed no brain waves. Blood gases showed an increased lactic acid and a ph of 6.8. He was in DIC, showing coagulopathy, with blood found in his urine, in his trach, and his nasopharynx. he had a significant pneumothorax, and i got to assist with putting in his chest tube. blood cultures and sputum culture from the chest tube showed enterobacter. all of his organs seemed to be shutting down, but his heart kept on beating...
So the story thickens... mom is a 14 year old girl, and dad is 17. Grandmother is the primary care giver to the patient and his mother, who is a pediatrics patient herself! there are rumors of co-bedding as well.
Being in that room full of people, being told that the youngest and most fragile member of their family won't make it was really difficult. hearing words like, "he will be in heaven", and "end his suffering" have only been applied to adults in my experience.
After being with the attending while that happened, i excused myself to go to the bathroom to cry.
He passed the following morning.
~*~
Two year old B.H. was happily playing in his mother's house when for a second, he was unattended playing on top of the stairs with a baby gate. Mom heard a crash and a tumble and saw him rolling down the stairs. he acted hurt momentarily, but then continued to play, but his activity level waned as the night progressed. the following morning (sunday), mom noticed that he was unable to climb up on the couch and grasp his water cup. alarmed, he was brough to the ED in an outside hospital where a ct was performed and read as a negative study. He was sent home with some decadron and nsaids and was told to follow up with his Pediatrician in 48 hours. As mom came in to see the pediatrician (tuesday), the pediatrician instructed the mom to return if he did not get any better or if symptoms worsen. and worsen they did. mom states that appeared to be less able to move his lower extremities. on Thursday, mom brought him back to the Pediatrician who instructed them to get a repeat ct in the hospital. The pediatrician got on the phone and called a radiologist to do a repeat read. and that's when another radiologist (apart from the first one who read the study negatively) states that there was indeed a lesion seen in the c2-c5 area.
the pediatrician sent EMS to the pick up the child from the home and was brought to the PICU.
he progressively became more flaccid and is today thought to be a quadroplegic. He underwent a laminectomy and myelomectomy on sunday.
palliative care is consulted. He was transferred to Atlanta for rehab after 15 days of PICU care.
His life is not in danger but forever changed. only time will tell if he will regain function again.
~*~
A 14 year old girl named F.W. has a history of seizures and was brought to the PICU unconscious after a near drowning. History suggests that she was at her grandmother's house, swimming after school, and although she had very close supervision during most of the afternoon her grandmother went inside for a few minutes to use the bathroom. Her grandmother then found her face down and unresponsive. Being elderly herself, she had quite the difficulty pulling her out of the pool.
F.W. is also involved in a long, drawn out custody case. She was currently living with her father and step mother, all the while, mom is fighting a court battle to get her back. Of course blame was thrown all around and DCF was contacted on the case. Mom was in court all day, requesting time to see the judge for a reversal of the custody granted to father and step-mom.
Meanwhile, F's heart is beating strong, she is on a ventilator, and an EEG proved her brain to be damaged due to a lack of oxigenation for an extended period of time.
It took a very strong and kind Peds Intensivist to intervene in this situation and say to Mom: "You can fight this in court all day but you will only get so much time to say goodbye to your child".
After both parents were able to reconcile some of their differences, they made the joint decision to give F's organs for donation. It was an incredible process.... the guilt and sorrow melted into purposeful action with the knowledge that their daughter can give a gift of life to several children. It is an incredible gift, and as F's step mom said, this is something F would have wanted. Her lungs went to a child in gainesville, her liver to a child in south carolina, her heart to atlanta... and the list goes on.
Perhaps the most difficult part of F's story is that she was a healthy, happy teenage girl prior to her accident (much in the same way that my healthy, happy teenage little sister is). And that is why her story really hit close to home. I I pray daily that my sister remains safe, but life really can change in an instant. F's story is testament to that.
~*~
that is it for now. that took alot to rehash all of it.
Reminiscing about Pediatrics
This entry is backdated: January 25th, 2011
Today i was thinking about how feeble my memory is. and how likely i would be to forget all the cool cases i had a chance to witness while i was doing my inpatient tour in the peds ward. and just to prevent that from happening, i wanted to jot a few really cool patients and cases down:
1. a 6 year old hispanic female who suffered a seizure and a stroke. She had a hemiplegia and had a very interesting neurological exam, with deficits on her right side. She even had a positive babinski. The most striking of which is that her parents had a very all hands on deck approach. Obviously, i saw her after her stint in PICU, so I'm sure that all the anger and difficulty, guilt or blame they may have felt has already been blunted by some time. But it was refreshing to see their family dynamic
2. A 20 year male, who is hardly a pediatric student, who as a child had an unknown kidney disorder which warranted him to get a bilateral kidney transplant at the ripe young age of 5. I meet him 15 years later in the emergency room as a new admit because about 5 years ago, he had the transplanted kidneys failure. They were then taken out and he now relies on dialysis two to three times a week. This was going well, until one of his fistulas that was put in two weeks ago did not take and led him to having severe bleeding. He called 911, and as part of the paramedics protocol, they infused him with a bolus to keep his blood pressure up. Unfortunately, he has a 1 L fluid intake maximum per day. Over the course of a few hours, the bleeding from the fistula had stopped, but he also had a different problem: he had developed hypertension. but since most antihypertensives work on the kidneys and the RAAS system, it became difficult to manage his blood pressure. He normalized eventually, but had to wait until the following monday to recieve dialysis.
3. A 13 year old white male who had kawasaki's disease as a child and had a 7 mm coronary artery aneurism when he was only 5 years old. He was lost to follow up and failed to reestablish cardiology care once moving to pensacola from texas. He presents to the ER in Fort Walton with chest pain that radiated down to his left arm. He was worked up as a rule out MI case, but was transfered over to the care of the pediatrics residents in pensacola due to the Nemours
4. Little W***t, a 5 years old boy with Hurlers; who has fevers and CRP that was trending up. He also has a metal plate placed in his left ankle. could his fevers be due to a myriad of reasons, but the most likely culprit was this ankle plate. Coincidentally, his pediatric orthopedist was not in house, but instead in Oklahoma, who is a specialist in his field.
5. A 3 year old girl with rectopharyngeal abscess. Obviously not an extremely interesting or unique case, but she proved to have an extremely difficult physical exam. Clinging on to her father's neck and not letting go because of the barrage of white coats that entered through her door during morning rounds, it makes sense that she was scared and intimidated.
6. E***, a 3 year old who has a new onset ALL; which was worked up due to his leg hurting. (interesting side note: I interned for the American Cancer Society, and found that E was definitely plugged into the system, getting access to incredible resources)
7. A 9 year old who had a desmoid tumor secondary to Familial adenopolyposis
8. A 7 month old boy who has hemophilia A, (lacking Factor 8), who then develops clotting in the tube despite the administration of recombinant factor 8. It was found that his Anti factor 8 was high, indicating an immunologic response to the recombinant factor. The brilliant people in Nemours decided to infuse him with activated factor 7a, which is further down on the cascade. However, this medication is extremely expensive. a previous case has shown that a child has used up half a million dollars worth of this medication. The same baby had a very interesting history: he also presented at 6 weeks with an olive sized mass and projectile vomiting, and was immediately worked up for a classic case of pyloric stenosis. He tolerated the procedure well, however his post op recovery was complicated by the fact that he was indeed a hemophilac.
9. Two babies with hyperbilirubinemia. little baby K*** was going to be discharged on the second day after triple photo therapy. however, her mother, who was preeclamptic during her pregnancy started having visual disturbances and was seen in the emergency room and was worked up for a possible stroke.
Thats all i can remember for now. I can't believe how exciting that time was. Theres a small part of me that wishes i could just know what i could be happiest doing. i'm afraid that there has been very few cases that stick out in my mind this much in adult medicine. and maybe this is an indication that i would be happiest (and the most challenged) being a pediatrician.
Today i was thinking about how feeble my memory is. and how likely i would be to forget all the cool cases i had a chance to witness while i was doing my inpatient tour in the peds ward. and just to prevent that from happening, i wanted to jot a few really cool patients and cases down:
1. a 6 year old hispanic female who suffered a seizure and a stroke. She had a hemiplegia and had a very interesting neurological exam, with deficits on her right side. She even had a positive babinski. The most striking of which is that her parents had a very all hands on deck approach. Obviously, i saw her after her stint in PICU, so I'm sure that all the anger and difficulty, guilt or blame they may have felt has already been blunted by some time. But it was refreshing to see their family dynamic
2. A 20 year male, who is hardly a pediatric student, who as a child had an unknown kidney disorder which warranted him to get a bilateral kidney transplant at the ripe young age of 5. I meet him 15 years later in the emergency room as a new admit because about 5 years ago, he had the transplanted kidneys failure. They were then taken out and he now relies on dialysis two to three times a week. This was going well, until one of his fistulas that was put in two weeks ago did not take and led him to having severe bleeding. He called 911, and as part of the paramedics protocol, they infused him with a bolus to keep his blood pressure up. Unfortunately, he has a 1 L fluid intake maximum per day. Over the course of a few hours, the bleeding from the fistula had stopped, but he also had a different problem: he had developed hypertension. but since most antihypertensives work on the kidneys and the RAAS system, it became difficult to manage his blood pressure. He normalized eventually, but had to wait until the following monday to recieve dialysis.
3. A 13 year old white male who had kawasaki's disease as a child and had a 7 mm coronary artery aneurism when he was only 5 years old. He was lost to follow up and failed to reestablish cardiology care once moving to pensacola from texas. He presents to the ER in Fort Walton with chest pain that radiated down to his left arm. He was worked up as a rule out MI case, but was transfered over to the care of the pediatrics residents in pensacola due to the Nemours
4. Little W***t, a 5 years old boy with Hurlers; who has fevers and CRP that was trending up. He also has a metal plate placed in his left ankle. could his fevers be due to a myriad of reasons, but the most likely culprit was this ankle plate. Coincidentally, his pediatric orthopedist was not in house, but instead in Oklahoma, who is a specialist in his field.
5. A 3 year old girl with rectopharyngeal abscess. Obviously not an extremely interesting or unique case, but she proved to have an extremely difficult physical exam. Clinging on to her father's neck and not letting go because of the barrage of white coats that entered through her door during morning rounds, it makes sense that she was scared and intimidated.
6. E***, a 3 year old who has a new onset ALL; which was worked up due to his leg hurting. (interesting side note: I interned for the American Cancer Society, and found that E was definitely plugged into the system, getting access to incredible resources)
7. A 9 year old who had a desmoid tumor secondary to Familial adenopolyposis
8. A 7 month old boy who has hemophilia A, (lacking Factor 8), who then develops clotting in the tube despite the administration of recombinant factor 8. It was found that his Anti factor 8 was high, indicating an immunologic response to the recombinant factor. The brilliant people in Nemours decided to infuse him with activated factor 7a, which is further down on the cascade. However, this medication is extremely expensive. a previous case has shown that a child has used up half a million dollars worth of this medication. The same baby had a very interesting history: he also presented at 6 weeks with an olive sized mass and projectile vomiting, and was immediately worked up for a classic case of pyloric stenosis. He tolerated the procedure well, however his post op recovery was complicated by the fact that he was indeed a hemophilac.
9. Two babies with hyperbilirubinemia. little baby K*** was going to be discharged on the second day after triple photo therapy. however, her mother, who was preeclamptic during her pregnancy started having visual disturbances and was seen in the emergency room and was worked up for a possible stroke.
Thats all i can remember for now. I can't believe how exciting that time was. Theres a small part of me that wishes i could just know what i could be happiest doing. i'm afraid that there has been very few cases that stick out in my mind this much in adult medicine. and maybe this is an indication that i would be happiest (and the most challenged) being a pediatrician.
~*~
The previous post was written on my live journal account over a year ago, while doing my third year pediatrics rotation. Reading this post in retrospect gives me such a funny insight: kind of like stepping stones that eventually led me to family medicine. Obviously, I did not pursue pediatrics, but I continue to have a strong desire to take care of children and families.
Friday, April 27, 2012
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