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!

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.

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.

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