19.white knuckles and sweaty palms from hanging on too tight.

[P!nk - Blow Me (One Last Kiss)]
[Album: The Truth About Love (2012)]

"clenched shut jaw, I've got another headache tonight."

Finally a chance to mull over the sights and sounds of a Pediatric Service.

3 weeks out of 8 total finished. Who would've thought Rounds would start at 6am everyday and last for 6+ hours? I expected them to be much longer than on a Surgical or other Sub-specialty...but 6+ hours everyday? Perhaps I didn't quite expect it to be THAT long. Oh well.

"I will breathe, I will breathe, I won't worry at all."

We do 3 weeks on an Inpatient Service and spend the remaining 5 on various Outpatient Services. I have had the unique opportunity to get assigned to the Pediatric Infectious Disease team and if I've learned one thing it's that Infectious Disease might be the only specialty I could live with if I were to go into something non-Surgical.

For all the impatient people. For all the obsessive-compulsive wrecks out there. This is the specialty for you -- without a doubt. A large part of the appeal that Surgical specialties have, in my opinion, is the unique situation where a problem has been identified and (hopefully) there is a definite procedure to solve that problem. Appendicitis? Take out the Appendix. Subdural Hematoma? Make a burr hole and drain it. Infant born without a biliary system? Re-route the jejunum of the small intestine and connect it to the liver to establish bile flow (hepaticojejunostomy a.k.a. Kasai procedure). 

It's gratifying. It's the hopeless romantic scenario of Medicine: find a problem and fix it. Sick patient becomes a healthy patient. Save a life. Provide Hope where before there was none. What other reason could one have to enter this profession than to do just that? Over and over and over again until you've justified your existence on this Earth or simply until you just can't anymore. That's Medicine.

"You think I'm just too serious, I think you're full of sh*t."

Infectious Disease, surprisingly, works in exactly that fashion. Every patient that gets admitted to our service has some kind of infection....some particular mix of bacteria, virus, fungus, and/or parasite that we must identify. We have to gather all the clues. Look at the greater clinical picture. Order appropriate exams and assign the correct procedures in the correct order. Once we find the bug(s) what do we do? We eradicate it. We fix the problem. In just the past 3 weeks I've seen the sickest and most miserable patients transform into the bright, youthful innocence that all children deserve to express and thrive on. The great majority of infections have a distinct cure and that's all ID cares about -- the Cure.

Nothing is more exhilarating than knowing you gave everything to one person and, in doing so, positively impacted their life so that they can go on and do amazing things -- a sentiment that is magnified in light of the limitless potential of sick kids that you high-five on the day of discharge as they hop and skip out those hospital doors to change the world. 

That's Medicine and Infectious Disease has been a good intro to Pediatrics.

"Blow me one last Kiss."

the crate -- 

Ignorance Ain't Bliss

In Infectious Disease, you're pretty much Sherlock...and I guess Dr. Watson all in one.

Patients are admitted to ID and consults are sent to ID when the pathogens, if any, are elusive and the diagnosis is a mystery. It's an event, a 6+ hour one in fact, watching the Residents and especially the Attendings come up with a massive list of Differential Diagnoses with another dozen etiologies and obscure variants -- taking everything possible into account. We've gone as far as asking if patients ever bleached their tubs. Or if they have somehow bit their upper arm. Or even if the patient's dog licked them in the eyeball recently. They've not only memorized all the possible diagnoses but they have inadvertently internalized all the ludicrous situations that might have occurred to give rise to what we are seeing clinically.

The Crates -- the shear breadth of knowledge -- that Infectious Disease specialists have on hand is ridic. I'm essentially spending most of my time googling every other thing that is mentioned, whether it's a bug and illness I've never heard before or one of a thousand different treatment/research protocols that suggest the best possible approach to the problem...I'm always huffing and puffing and trying to catch up. Literally, figuratively, and everything in between.

"Tie a knot in the rope, tryin' to hold, tryin' to hold."

Some of the most common diagnoses?

From my experience I have to say the vast majority of cases (especially with it being one of the worst winters in Detroit history) are viral Upper Respiratory Infections (URIs)...usually due to Respiratory Syncytial Virus (RSV). A close second, and one we'd often have to rule out when diagnosing URI secondary to RSV is Pertussis or 'Whooping Cough.' Aside from those some notable contenders are your standard Strep Throat infections due to Streptococcus Pyogenes and an uncommon vasculitis I thought I would not see beyond textbooks -- Kawasaki's Disease (we probably had 3-5 cases of this).

In any case of acute or chronic infection the work-up was always tense. There aren't many other things out there that are scarier than the unknown -- part of the reason why a good number of Pediatric Patients are started on Broad-Spectrum Antibiotics that cover a plethora of likely organisms before we even know what's going on. Better to be safe than sorry.

"But there's nothing to grasp, so I let go."

It's natural to feel helpless when you have no idea what's going on. For that reason, perhaps the most useful Crate I've learned on this service is to keep our patients -- especially and most importantly the Parents -- informed about what's going on. We have to explain every lab test and imaging modality down to every nitty gritty detail. We have to explain the dosing schedule and coverage of every antibiotic. We have to justify the amount and location of every IV, PICC line, gastric tube, and why/why we are not providing food and/or maintenance fluids. It'a a festering marathon...and all the while we are trying to find out what is wrong and how to fix it....for multiple unique patients.

but You Only Live Once....and we wouldn't have it any other way.

On Infectious Disease we don't like Unknowns and we know our Patients don't either.

When you're sick you think of the Doctor. Doctor is supposed to handle the rest.

This is Medicine.

the hippo -- 

Ignorance is Pissed

Parents are also Doctors. Especially in this age.

They, however, can go from the well-meaning and mild-mannered Dr. Jekyll to the less pleasurable Mr./Mrs. Hydes...and you can't blame them.

"I think I've finally had enough, I think I probably think too much."

On more than one occasion we may have been the 3rd, 4th, and in one case the 7th set of Doctors that the Patient and Parents have seen regarding a difficult and amorphous illness. The spectre of the Unknown grows with time and every 'inconclusive' or 'indeterminate' test/exam. 

Are we not Doctors? 

Aren't we supposed to be the ones that Heal and Revive and Cure?

What some Patients and Parents don't realize is that we are just as frustrated and stressed out. That we are also losing sleep, appetites, and integrity within our personal relationships. Although we are all on the same team, until the Diagnosis is made and the pathogen identified it's common for the medical team to be viewed on the same side of the fence as the disease. It's a difficult position to be in, but when I think about it I would probably be just as Hulk fierce as any Parent were it my child in the same predicament.

"I think this might be it for us."

That's why the ID Hippo is identical to the Crate -- keeping everyone informed is the best weapon with which to slay the Unknown, the Unsure, and the "I thinks." Ignorance is, frankly, not bliss. It's a temporary state of falling and numbness with no end in sight. Although every Patient is unique and may have a different pathophysiological process going on there is always this one common ailment that Doctors have to manage and cure as well.

"My head is spinning so, blow me one last kiss."

We give Broad-Spectrum Antibiotics to fight the literal/tangible disease when we don't know what we are fighting. Similarly, I've realized theres a need for Broad-Spectrum Patience and Anti-Unknown...ics.

Overall, the best thing we can do is be as real and as straight-up as possible. No one likes hedging. No one likes guessing. No one likes assumptions or passive-aggressive tactics. I admit to being the biggest perpetrator of all the above which is why it's one of the things I'm working hardest on...to be painfully candid, truthful, and upfront no matter how difficult it is -- because it's the right thing to do.

At least this way we can all be pissed off together. We can be frustrated and scared together. No one gets left in the dark because at bare minimum everyone is on the same page and a common goal is in sight. Let's freakin' do this.

More than Bugs and more than Drugs.

Doctors need to give more Hugs.

This is Medicine.

Just when it can't get worse, I've had a sh*t day.

You've had a sh*t day?

We've had a sh*t day!

I think that life's too short for this.

So blow me one last Kiss.

17. alright. already. the show goes on.

[Lupe Fiasco - The Show Goes On]
[Album: Lasers (2011)]

"All Night 'til the Morning, we Dream so long."

It has been too long -- now that would be the understatement of the year, yes?

Though a fitting one on this final day of 2013. 

Time is either too fast or too slow, never in between. Meh.

The last month of my Surgery Clerkship actually ended about two weeks ago but the opportunity to come back to sunny California and a return to the world of the living has been so blissful and occasionally outrageous that I've only now found a wrinkle of calm to write. Alright.

But Life is the biggest Stage and like all grand Performances: The Show Goes On.

"Yeah, ain't nobody leavin', nobody goin' home."

Where before I spent my first month on the General Surgery service I spent my second with the Pediatric Surgeons at the Children's Hospital of Michigan. Where before I thought I was busy beyond belief, I quickly learned that 'busy' is a relative term and that revised definitions were in order for much of my vocabulary and lifestyle. The hours and required studying slash research were ridic.

I can say without a single molecule, nay a single quantum, of doubt that my month on the Pediatric Surgery service was the best month of Medical School thus far. And although I would really love it, actually, if I were to eat my words at a later date...I am fairly certain that no other Rotation or other remaining Medical School experience will ever compare (perhaps Match Day and Graduation will come close =p).

"Anybody ever wonder when they would see the sun go?"

It wasn't always fun. It wasn't always happy. And there was never enough ice cream or pancakes. But a big aspect of the experience was that it was piercingly real. It was harsh, but it was also innocent. I can understand how the world of Medicine and Surgery can be draining and soul-devouring, but I could not fathom until now what people meant when they said "kids keep you young." Because they definitely will, and they just might be the ultimate vanguard against the spectre of 'jaded' physicians shambling about like an episode of the Walking Dead.

Goodness knows I'm the biggest child out there -- but the privilege of working with Pediatric Patients has been jarring in the best way possible. It's very possible that Neurosurgery has met a worthy opponent. Never did I think.

Those Kids were something else.

"To tell those kids that's livin' in the ghetto, that 'the World is Yours'."

the crate --

The Parents

It's funny now. The first piece of advice we ever receive and internalize as Medical Students entering any Pediatric Service is to watch out for the Parents. 

"The kids might be cute, but the Parents can be vicious."

Naturally, that was my single biggest worry walking in on Day One. It makes sense doesn't it? I can easily picture how overprotective and overbearing a parent can potentially be...I mean, it's their single most important treasure...no one better do anything to harm their little shnickles (not made up).

"One in the air for the People ain't here."

The funnier thing is that, for the most part, this advice has rarely been true. I've seen defensive and even angry parents but never have their reactions been disrespectful or out of proportion in my humble Medical Student opinion. 

"Two in the air for the Father that's there."

All of this was a relief, because the Parents play a gargantuan role in the care of any Pediatric Patient. They are our primary source of information and are usually who we turn to for an accurate history regarding any illness and/or injury that happens. What I didn't necessarily expect, however, was how important the Parents were in delivering actual Patient Care. I knew the Parents are almost vital for moral support and when explaining procedures. In Pediatric Surgery, however, the Parents played an incredibly active role: walking their children to speed up recovery, unclogging nasogastric tubes, and even calculating bowel/urine output so that the nurses and Medical Students didn't have to.

The most endearing part? It's almost expected to picture the nurturing mother performing all these activities. But. At least in my experience, probably 80% of the time it was the fathers who were in the room being the stalwart caretaker. Those grisly fathers. And get this...in those cases the mother was also a bread-winner...how is that for a wonderful reversal of traditional roles? It's not perfect but this is a pleasantly unique age we live in.

"Three in the air for the Kids in the ghetto."

The Kids

Ready for more comedy?

The picture that is painted of caring for Pediatric Patients is one filled with running, screaming, crying, and a lot of miscellaneous bodily secretions. Hardly true as well -- I feel like this is an episode of Mythbusters.

Much of the challenge I've come to realize, however, is just how different it is to care for a child as opposed to an adult. The illnesses are different. The susceptibilities are different. We have to use appropriately downsized equipment. We can not use certain medications. Getting an IV started is extremely hard and frustrations can mount when these lines are somehow pulled out every other day.

"Four for the Kids that don't wanna be there."

It required a lot of adjusting. I'll volunteer my opinion that it definitely takes more time and patience to care for Pediatric patients. In addition to comforting slash caring for them you must also explain and appropriately brief the Parents. Despite this, however, nothing in my experience thus far has been more rewarding. Pediatric patients don't want to be sick. They hate being in the hospital. They are not seeking narcotics, don't smoke, don't drink, and have not taken on other detrimental life choices.

"If you are my homeboy, you'll never have to pay me...

...go on and put your hands up when times is hard...you stand up."

The best part? As fragile and unassuming as they may seem, Kids are some of the toughest and most resilient individuals I've had the privilege of working with. They recover so well. They heal quickly. They bounce back even in the most dire of situations and go immediately back to coloring outside the lines of their Spider-Man coloring book. As a hopeful aspiring Physician nothing is more gratifying than good outcomes -- and there is no greater bonus on top of that than the hilarious innocence of a laughing child drawing stick figure tattoos on your forearm that you later have to explain to colleagues and Attendings.

Those Kids are something else.

"Raise 'em 'til your arms tired, let 'em know you here...

...that you struggling, survivin', that you gon' persevere."

the hippo -- 

The Grown Ups

"Dealing" with Parents -- that misguided piece of advice I mentioned before. That was the initial Crate bestowed upon us as naive Medical Students, but after going through a month on a Pediatric Service...without fail...a Hippo reared its head to reveal the true nature behind this sentiment.

If Parents were not difficult, if they didn't raise their voice, if they did not "hassle" us with questions and complaints. That's when I would be worried. That's when I would be afraid. I've come to be comforted by defensive and sensitive Parents because it means that they care. It means they're passionate, and if they weren't so then there are bigger issues going on.

"Even if they turn the lights out, the Show is goin' on."

So much can be inferred by the interactions between Parent and Child. There is a lot going on even when nothing shows and nothing is said. On more than one occasion, unfortunately, we've had to file a report with Child Protective Services. Without going into detail all I'll say is those trouble Parents were the pleasant ones. They were the Parents who were overly friendly, who were cooperative, who never made our lives difficult. Now that is scary. Grown ups who can plot and plan are scary.

"That glitterin' may not be gold, don't let nobody play me."

So bring on those savage and vicious Hippo Parents. I welcome them. Of course there is a limit and of course there is a fine line between caring and caring so much that it is detrimental. But I'd rather have the Parent who makes my life harder and the Parent who keeps me on my toes than the fake ones who shower me with uncomfortable praise.

H*ll yeah I'll "Deal" with them. All day err day.

"So no matter what you been through, no matter what you into...

...never ever put them down, you just lift your arms higher."

The Tiny Adults

Bringing a child back to health and happiness has to be the most gratifying and fulfilling feeling that exists -- yes I've mentioned this before. I'm hella redundant and I don't even care.

What's the Hippo here though? What's the intangible lesson?

I realize it lies in the question of why, exactly, it feels so good to help kids. While on Pediatric Surgery I've come to learn that it's more of a twin-headed Hippo. A Twippo if you will. 

Here's #1:

"Have you ever had the feelin' that you was bein' had?"

"They be lyin' through they teeth, hope you slip up off your path."

As aforementioned, Kids don't like being sick. They rarely ever hide anything or have secondary agendas. All they want to do is get better so they can get back to playing and exploring this wide-eyed world we all live in. To me the thought that hit home was that these Kids usually have not done anything 'wrong'. They are pure victims most of the time. They don't have this heart condition because of poor diet and lack of exercise. They don't have this cancer from years of smoking or IV drug abuse. They aren't seeing you for the millionth time because they refuse to listen to your advice and recommendations.

This is how Medicine is supposed to be isn't it? Healing the sick and the dying. Caring for those who need it the most and can not help themselves. Devoting one's life to the preservation and well-being of the human race. For the skeptics, that Medicine still exists and these responsible Tiny Adults (oftentimes more responsible than actual Adults) are the Vanguard.

Here's #2:

"Five in the air for the teachers not scared."

Not only can these Tiny Ones be as responsible as Adults (not making bad choices), but there is the opportunity to make sure they become Big Responsible Adults as well. These are the formative years. This is when we can teach, and guide, and nurture so that future generations surpass our achievements in every way possible. When Kids grow up and outdo us, that's when we know we've done a good job.

"Yeah, the World is Yours, I was once that little boy."

It feels especially fulfilling because we have all made mistakes in our lives -- me most definitely. That's why, in addition to everything else, this is an opportunity to do what we can and make sure there are no repetitions when it comes to our own mistakes. Now this is the kind of redundancy I do care about. There is no way I'd let these Kids -- those with the greatest and brightest potential -- make the same errors and miscalculations.

"Africa to New York, Haiti, then I detour...

...Oakland out to Auckland, Gaza Strip to Detroit."

"Say hip hop only destroy, tell 'em look at me, boy."

At the end of it all, we've also made a lot of right choices. When the show never stops we have to minimize the bad and maximize the good because we only get one shot at Life -- we only get one Performance. So we better make it a good one.

This Pediatric Twippo -- the twin-headed unspoken Hippo lessons from Pediatric Surgery -- have become ingrained within me like nothing else thus far. It was a great way to close out 2013. Given all that is troubling the world today it's nice to have some light and some hope. I would be honored to care for these Tiny Adults -- our Vanguard against the perfect imperfections of Human Nature.

Those Kids are something else.

Happy New Year Everyone!!

Just remember when you come up, 
the show goes on.