Wednesday, July 14, 2010

The Rheumatological Posse

So, I meant to write this a while ago. Alas, that didn't happen since I've been unusually busy and things have been rather hectic. My peds externship is already more than half over! Wow how time has flown.

I'm on my pediatric rheumatology (peds rheum) placement for the remainder of this month. And while I don't think I'll go into peds rheum, it's pretty interesting. All the people I've been working with the last week and a half have been great as well.

Last Tuesday I met with Dr. N, the attending who's responsible for me, and two of the fellows, Dr. K (1st-year fellow) and Dr. C (2nd-year fellow). Peds rheum is a 3-year fellowship that one does after a 3-year pediatrics residency. I must say, Dr. C was adorable! He's this cute little Asian dude who has an adorable smile and voice. Yes, I may have a tiny crush on him. Alas, he kept pimping me last week.

What is pimping you might ask? Well, pimping is where a senior medical person asks a series of questions on medical facts to a younger medical person to test the limits of their knowledge. Often it's done in a way to embarrass the younger person and "put them in their place." Earlier, Dr. N and Dr. C had discussed an article that came out called The Art of Pimping. In there is a section on how to defend oneself from being pimped; I particularly like The Muffin, lol. Anyway, Dr. C pimped me on shingles, which I hadn't formally learned about but because I know a little bit about it in the past, I got all but one of his questions correct. Later in the week he pimped me on how aspirin works in the body. I blanked and couldn't remember, but I finally gave the correct biochemical pathway (whew!) after he kept pressing me for an answer. If only he weren't so nice otherwise and adorable . . .

Anyway, my peds rheum placement is quite amusing. There are so many of us on this month! There's me (representing M1 and M2), a M3 who's in clinic once a week, a M4, 2 interns (1st-year residents or PGY1s), 1 second-year resident (PGY2), 1 first-year fellow (Dr. K), 1 second-year fellow (Dr. C), and 1 third-year fellow (Dr. S) in addition to the 5 attendings. I spent a lot of time with the M4 and she's been great in explaining things to me and how rotations work during M3 and M4 years. The residents and fellows were all great to get along with as well.

So my time in peds rheum is devoted between 2 primary things: clinic, and inpatient wards. Of those 2, the majority of my time is spent in clinic. On the first day I had no idea what peds rheum was all about, except childhood arthritis. By the end of the week, through clinic, I learned that peds rheum covers a lot of diseases, such as: juvenile idiopathic arthritic (JIA), psoriatic arthritis, spondyloarthropathies, Raynaud's phenomenon, and lupus amongst many others. By the end of the week, I had seen at least one kid with each of those. Since there are lot of us, often 2-3 of us would go in with a fellow or attending to see the patient. I'm sure many (if not most) of those kids felt overwhelmed when 3-4 people walk into a room together.

Inpatient wards generally aren't busy because peds rheum don't get many consults. Last week we only had one kid that we were consulted on. I'm going to call this kid "Kid of the Week" or KotW. So we, the 8-person rheum posse, see this kid on Tuesday. He presents with some minor neurological symptoms, and we don't really suspect anything rheumatological going on with him. So we leave a note suggesting it might be CNS vasculitis or something and leave it at that. The thing was that the areas of his brain that're affected made it practically impossible to confirm CNS vasculitis without destroying brain matter along the way to finding out.

By the following morning, the kid had several mini-strokes and his neurological symptoms had worsened, so they sent him down to the PICU (pedatric ICU). When we arrived we encountered a very irritated critical care attending. Shortly after we arrived, the neuro consult team arrived. The critical care and the neuro attendings started arguing in the hallway about how to care for this kid who's rapidly deteriorating in front of us. After the critical care guy calmed down a bit, we talked to the neuro team and see if they also agreed that it was CNS vasculitis. Neuro sent KotW down for an angiography of the brain while we started his treatment, even though we didn't have a definitive diagnosis (but to not treat him was less risky than the possibility of him worsening, so we decided to treat what was most likely the problem).

The following day, the results of the angiography seem to "confirm" our diagnosis. Of course, the fellows and the attending on service were skeptical because CNS vasculitis is very difficult to "prove," and it technically couldn't be proven in this case since it was so atypical (apparently). Also, none of us could interpret the films, so the rheum posse trekked down to radiology so we could find someone to interpret it for us. I do not want to be a radiologist. The room they were in looked and felt kind of like a bat cave. It was very dim so that the radiologists could see their computer screens more clearly. The only other source of light were desk lamps pointed away from the screens, which gave an odd ambient glow. Also, the radiologists were talking in low voices into their microphones to dictate their findings and notes; it kind of sounded like a low constant drone or perhaps chanting . . . as if they were all in a cult or something.

Well anyway, it seemed that the radiologists couldn't help us, so they directed us to interventional radiological neurology (I didn't even know one could specialize that much). So, someone there explained the films to us, and we mostly nodded in agreement because we had no clue what we were looking at (I'm sure even the attending with us had no clue - all those tiny tiny blood vessels just look like squiggly messes to me). So long story short, we think our diagnosis is correct and that KotW was getting better. They decided to keep him over the weekend to monitor him and see how he did.


Anonymous said...

I say this with as much love as possible Long very very long very very bad for a adhd teen Love<~Peter~>

Biki said...

It's very interesting to me how often medicine can't "prove" what the ailment is, but is it really imperative to "prove" it anyway? If the treatment relieves the systems and the patient improves, the s'all good yeah?

My hubby had to endure 4 months of being quite ill, and going thru many tests, only for each test to come back negative for gall bladder failure. Finally the surgeon went ahead and operated, and yup his gall bladder was shot. The doc said, "Twenty years ago I would have just trusted my instincts and operated on him right away, but now with malpractice being what it is, we test, test, test....."

Ron said...

I lol'd so hard when I read: "Yes, I may have a tiny crush on him. Alas, he kept pimping me last week."

As you told me this story last week (or was it earlier this week), i was sorta just thinking about the whole idea of medical practice in the United States. There seems to be a culture of excessive use of high-tech diagnostics in the US.

I think I've told you that before on MSN or something. Sorry, no offense. It's just something I've noticed, I'm not saying it's a bad thing all the time. But sometimes it can be. But with litigation in the US i can understand why docs do it. And plus the massive healthcare expenditure gives some leeway for physicians in the US to have many resources, which is good but - I'm not gonna go into detail about how it can be a bad thing, I think you know what I'm talking about.

and lol yes i was at radiology once and they live in caves where the sun don't shine.

LOL "as if they were all in a cult or something."

yeah interventional radiological neurology, I've never even heard of that. I've know interventional radiology but...

oh wait i actually have heard of it but it was worded differently, rather:

interventional neuroradiologist :)

Lol I love it how there are times in medicine when you, as the medical student, know that the attending/consultant has just as little clue as you do! :D

glad to hear kid of the week is doing better.


naturgesetz said...

It's always a bit surprising to be reminded that diagnosis is not always a sure thing. And as a result, treatment can be informed guesswork, with a certain amount of trial and error. But even if it is guesswork, it gives the patient the best chance possible.

Let us know how KotW does (if you find out).

Aek said...

dpking19: Yes, this post borders on novelette in comparison to most other blog posts. Alas.

Biki: Thing is, we had to be as sure as possible, because the treatment we would give would mask any potential malignancies (cancer). And if that were to happen, he'd come back in a couple months in a MUCH worse situation.

Ron: Yes! Interventional neuroradiologist, that was the term I was looking for, lol. And even if there are windows in the radiologists' rooms, they always have the blinds completely closed anyhow. With this kid, we were throwing everything including the kitchen sink at him (though, as the neuro consult team said, we had to know WHICH sink to throw).

naturgesetz: Yeah, sometimes the diagnosis and treatment are tenuous, but we try to minimize that as much as possible. KotW turned out just fine, but you'll have to stay tuned to the next post. ;-)

letopho said...

I got shingles last year. I can tell you all about it.