Life can be hard to understand

Here, I work in the nursery and in the neonatal ICU and I get to see these little bundles of cells as they enter the world. Many enter with so many things against them you wonder how they will ever make it. I have a patient who was born to a 14 year old street child. There was no prenatal care. The fetus was exposed to many toxins including cocaine, alcohol, marijuana, nicotine, alcohol, amphetamine, heroin, and many other poisons. The infant was born 10 weeks premature and can barely muster enough strength to get a breath. The mother is developmentally challenged and can't read or write and even struggles with speaking. She only went to school until 3rd grade and the father is in prison for life for gang related murder. I do not know anything about his drug abuse or education. He obviously has violent tendencies and who knows what other struggles he has. 

Now you have a newborn baby without a present father and with a damaged mother. The infant has suffered from drug abuse and premature birth. He has underdeveloped lungs and signs of possible brain damage. The state will put the mother and her child when he is well enough into a home. Most of these mothers do not stay at these homes because there are rules and they are not allowed to use drugs or smoke. Most likely this infant will end up either on the street with his mother or in and out of different living circumstance for much of his childhood. The odds are so staked against this infant from an intellectual, health, financial, shelter and basic necessities that I can't help but wonder how will this child ever contribute to society. This cycle repeats itself over and over again. His parents were raised in similar circumstances and their parents were probably exposed to the same environment.

I do not have the answer nor am I naive enough to think that I can make a significant impact. I just try to get the infant through another hour and another day. 

Nursery

Today I started in the nursery / neonatal care. What is this entail? It is like its own specialty within pediatrics. The nursery has specialized physicians and nurses who work in and run the nursery. Given that neonates require different treatments and interventions than older children. A regular pediatrician is certainly trained to work in the nursery, but often hospitals will have neonatal specialists that regularly work in the neonatal ICU (NICU). Basically the nursery houses the newborns until they are ready to go home. The NICU houses the newborns with major health problems. 

Today I had 2 new admissions that I was assigned. The first infant was girl with jaundice. I placed the infant in the phototherapy unit. There are many things that can cause jaundice in a newborn. Often it is benign, however when it occurs in the 1st 24 hours and or comes with high bilirubin levels then there can be some complications that require aggressive treatment. In this infants case the jaundice was present at birth which is not a good sign and the bilirubin level was elevated beyond physiologic jaundice. If high bilirubin levels go untreated and continue to rise the infant is at risk for kernicterus which is basically brain damage caused by the bilirubin. I ordered a variety of test with the help of my attending physician. Ultimately a test that indicates ABO blood incompatibility came back positive which means that the mothers blood makes anti-bodies against the babies blood attacked the infants blood in utero causing hemolysis which releases bilirubin leading to hyperbilirubinemia manifested with jaundice. 

How is this treated? We continually monitor the bilirubin levels while keeping the infant in the phototherapy unit. The UV-B lights help rid the body of the bilirubin and treat the jaundice. Usually this is all the baby will need and often a baby with ABO incompatibility may not even need phototherapy. Once the baby is born the mother's blood no longer has access to attack the babies blood. Other times if it is severe the infant can require exchange transfusions to clear the bilirubin.

My second admission was a child born prematurely to a mother that was a heroin addict and tested positive for THC (marijuana). So this child was withdrawing and in a bad state. 

My heart hurts for you

I got this baby as a patient that was 2 weeks old and had a chief complaint of wheezing and difficulty breathing. Chest Xray in the ER showed signs of bronchiolitis possibly related to RSV. The baby was admitted and we began to treat the infant and give oxygen. We were able to get the symptoms under control and within 2 days we had the baby breathing well and almost all symptoms were gone.

On the morning of the 3rd day I examined the baby and I was hoping to discharge the baby that day. As I was listening to the lungs I heard some irregularities with the heart. I made sure to listen and re-listen to verify that I was actually hearing a murmur. I was pretty certain that I was hearing a murmur that is heard with patent foramen ovale (PFO) which is a hole between the right atrium and left atrium. It usually closes when the baby is born and is considered an abnormality if it does not close. It can be benign depending on the size of it and will sometimes close with medication or after 4-6 months.

I called in my senior resident to listen and he verified that there was a murmur and told me good job for picking up on it. We presented the case to the attending physician at morning rounds and he listened and agreed with our assessment. So we ordered a EKG and echocardiogram. That afternoon we did an echocardiogram and were surprised at the pathology we found. There was a significant hole between the left and right atrium and a hole between the aorta and pulmonary artery and  there was significant right sided hypertrophy. The baby has some serious problems with her heart. I had to explain to the parents what the issues were and also explain that until we did further tests we were not certain what was wrong.

The parents were devastated that there was anything wrong. This is their first baby. We had to keep the baby in the hospital and ordered a multitude of tests to try and figure out what is wrong with the baby. Often these kinds of heart issues are part of an entire syndrome and can be fairly serious if not fatal. Currently we are waiting to do more tests and trying to solve this riddle. In the meantime the parents wait anxiously without any idea of how it will all turn out.

WHat do you do with a infant and fever.

I saw a couple of these when I was rotating in the pediatric ER back in the fall. Here is the scenario. Infant under the age of 2 months comes in with a fever. The fever in a newborn is defined as a temperature of 100.4 or higher. A newborn with a fever gets a full work up. The first time you see this kind of work up it can be a little unsettling. You looking at a infant that does not look that sick but does have a fever above 100.5. You know that it is probably nothing but you have to do a full work up.

A full fever work up for an infant includes basically poking in every nook and cranny to ferret out the source of the fever. This includes a straight catheter and a spinal tap. The parents are freaking out and the healthy looking baby is now traumatized and bleeding from the spine. In the end the infant usually gets admitted. Eventually the source is hopefully found and the treatment is tailored accordingly and if no source is found the infant gets empiric treatment. Why all this torture over a small fever? 

You can't run the risk of missing meningitis in a newborn. Even though the odds are slim, a newborn can't communicate their symptoms the way older children can so you have to assume the worst. Every few years a case is missed and a newborn dies or suffers deafness or other consequences of meningitis. I think that there are roughly 300,000 or more negative spinal taps etc done for every 1 case of meningitis found in newborns. Even if your newborn does not get meningitis, if he / she gets a fever and you go to the hospital the work up will be traumatic and even possibly dangerous (rarely) but it is better safe than sorry. This is why I think newborns should be guarded from any exposure which means no church or other mass gatherings for at least 2 months.

I have had 3 cases this week of fevers in newborns and we did full work ups including spinal taps in each case.

Strange Teen

The other day I get assigned a patient who was a 15 year old girl who had been admitted by her primary care physician for anemia. I go into the room and she was lying in the bed and she had a very non-trusting look on her face that screamed out "don't even try to talk to me.......but please give me some attention!" I started off with small talk to try and gain some trust and as she caught on that I was actually interested then she started to open up.

Her history included: Her mother is in prison and her dad has not been seen for years but the last time she saw him he was sexually abusing her. About 3 months ago she got an abortion and had not stopped bleeding from the procedure and the details regarding the abortion are somewhat sketchy and we were suspicious as to whether or not the abortion had been performed in an actual clinic by a doctor or performed on the streets by a stranger. She was not forthcoming with the details of the abortion. She has had many sexual partners and all kinds of sad stories of abuse and neglect. The state took her as a guardian when her mother went to prison a couple of years ago. She has been bouncing around foster homes and state facilities for the past 2 years. She has a long history of drug abuse and has dropped out of school. 

During the history I was able to ascertain that she has been eating baking soda for 3 + years now in very large amounts. She described that she has an insatiable desire to eat baking soda and can't stop. She steals it from stores and eats nearly 4 full boxes / week. It was fascinating to hear her discuss this and then see that she had snuck in several boxes of baking soda into the hospital. I figured that we could ad Pica to her diagnosis. Pica is a disorder in which a person repeatedly eats non-food items like clay, dirt, metal, paper, feces, etc. The disorder is most common in children, pregnant women and mentally retarded persons. The cause is idiopathic (unknown). Sometimes underlying iron deficiency or zinc deficiency can lead a person to eat non-food items like clay or dirt. This patient had a low serum iron which was most likely due to her persistent bleeding from the abortion. Pica is fairly uncommon but it is seen and most often considered a psychiatric disorder.

I consulted OB/GYN due to her bleeding and I consulted Psychiatry for the Pica. The psychiatrist said that he will see a couple of cases of Pica each year. I also got social workers involved to find her a group home or program that she could attend to get help for her psychiatric issues. What a fascinating case but also sad. This poor girl never really had a chance. Here genetics and her environment were both stacked against her the day she was born. Who knows where she will end up? I discharged her today as we were able to stop the bleeding and get her anemia in control.

Perianal Abscess

Last night a hispanic couple shows up with their 11 month old to the ER complaining that the infant has had a fever of 101 for 2 days and has been vomiting and having diarrhea for 2 days as well. The ER docs examine the patient and decide to admit the patient for fever of unknown origin and infection of unknown source. 

The infant was admitted to the pediatric floor where 3 residents and 1 attending physician each examined the patient separately and came to the same conclusion as the ER doctors. I came in this morning and the patient was assigned to me so I proceeded to examine the patient. As part of the exam I begin to remove the child's diaper and the mother started to protest and ask why I was removing the diaper. I explained that in order to do a full exam and to attempt to determine the source of the fever and the infection it is crucial to examine the entire body. I was able to comfort her and explain what I was doing. She explained that none of the other doctors did this but ultimately gave me permission to continue my examination. Patients often protest to having to be fully examined, most time the parents are fine with the doctor examining the baby naked but even they protest at times. Many doctors will not do a full exam for this reason. They wont ask the patient to disrobe for a full exam even if it would be relevant to the exam. Obviously you do not have a patient disrobe for a flu shot but many exams to be complete should include inspection of all the areas. 

As soon as I removed the child's diaper and began to examine the baby I noticed an inflammed area right next to the anus. Upon further examination I was able to determine that the baby had a perianal abscess which was most likely the culprit for the infection. As I palpated it I could tell that it was large, tender and warm to the touch (I could feel the warmth through the gloves). There are many ways a child can develop such an abscess and they are often missed by the parents because unless you a really looking carefully at the anus it will appear normal to them. I brought in my chief resident showed her my triumphant finding. We had already started the baby on antibiotics but now we were able to aspirate the abscess and send the fluid to the lab to be cultured and upon the results we may start a different antibiotic depending on what kind of organisms are present.

The whole experience reaffirmed the importance of being thorough and also not being thrown off by the patient's or the patient's complaint about part of the exam. You have to have permission but you also do what you are trained to do and remember that the patient is not the one who went to medical school or the one who is liable. One great doctor I have worked with was great at explaining to the patients why a certain exam or test was necessary and ultimately was successful in gaining permission. I asked him what he does if ultimately the patient refuses the exam and he told that he tells the patient to find a different doctor, in a nice way of course. In talking to the residents they mentioned that the mother protested many parts of their attempted  exams. The doctors who examined the patient before me were not bad doctors at all, in fact they are good doctors but they did not want to make the patient, or in this case the patient's mother uncomfortable so they failed to do a complete exam and thus failed to make a diagnosis by allowing the patient's mother to run the exam. 

Strange Babies all around

Today I finished early and had some time to kill before an evening lecture. So I went over to the hospital where the lecture was going to be. I was excited about the lecture because the doctor giving the lecture is a renown pediatrician. As I was waiting and studying (I had about 3 hours) for the lecture I ran into the doctor who was going to give the lecture and he asked me if I wanted to come and work with him. "Of course!" I said. 

He took me to the nicu to look at 3 very interesting cases. He made me work through the diagnosis on my own and I was able to figure out the cases. The first case was a 2 day old baby born with microopthalmia which is a condition where one eye does not develop correctly and remains very small and nonfunctioning. The baby will be blind in that eye. As I was examining the 2nd baby I noticed that the heart sounds were much more profound on the right side of the chest and I was able to determine the baby had dextrocardia. Dextrocardia is a condition where the heart is on the right side instead of the left side. After reviewing an Xray of the baby I was able to further realize that the baby had Dextrocardia Situs Inversus Totalis which is when all the organs are on the opposite of their normal location. It is a direct mirror image. This syndrome occurs when there is a defect in the cilia that are responsible for moving the organs as they develop. I included an xray of a patient with dextrocardia situs inversus totalis. 

Finally the 3rd case was a baby with Harlequin type ichthyosis which is a disease where the skin is too thick and contains massive scales. The baby literally has thickened scales. The skin is thick and causes toes, limbs etc to infarct by cutting of the blood supply to the areas. The skin is defective and lacks its normal protective barrier qualities so these babies to not due too well and usually die of infection. The prognosis is grim. There are some isolated cases where a harlequin babies have survived into adulthood. This particular baby's parents left the hospital never to return upon seeing their deformed baby.  It is a sad case. The baby is about 1 month old and struggling to survive. I included a picture of this disease as well.

It was a great day and I was able to see some fairly rare cases and work for several hours with one of the major experts in the field of pediatrics.

Happy New Year and welcome back

This morning I had to get up at that all to familiar hour of 4:00 am to get into the city in time for my orientation for the pediatrics rotation. My first orientation was with all the students from my school who are currently starting their pediatric rotation. We have about 6 different locations affiliated with my school. After that orientation I had to hurry with 2 other students over to our hospital where we are doing our rotation for a 2nd orientation. Basically we are given access to the computer systems, briefed on all the different protocols and given ID badges. We were also given our schedules. 

I am doing inpatient care for the first 3 weeks and out patient clinic for the last 3 weeks. I should see a good mix. Once my 2nd orientation was over we were dropped off at the pediatric ward and put to work. The main attending who I will be working with for the next 3 weeks is out of town so we reported to the residents who were not to informative or talkative. I was assigned my first patient which was interesting.

My patient is a 16 month old male who was playing unsupervised in the garage and when his mother came out to bring him inside she saw that he had an open jar of paint thinner that he had spilled down his chin and it looked like he may have drank some as well. The mother brought him to the emergency room where he was not in any distress. The emergency department physician decided to admit him for observation as we could not be sure whether he consumed paint thinner or not. The patient's mother and father were both there and they only speak spanish. They have 6 children ages; 14, 11, 8, 5, 3, 16 months. Neither of them could explain why the 16 month old was playing in the garage in sub zero weather unsupervised. I did a full physical exam of the child and spoke with the parents at length. The child did not seem to be in any distress and a chest xray showed some possible infiltrates which could be pneumonia or could be from aspiration. The xray was really inconclusive. I noticed that the same child had been to the ER a couple of months ago for aspiration of a foreign body which basically means that the baby chocked on a toy or something he put in his mouth. 

The chief resident talked with poison control and we basically decided to keep the patient overnight for further observation. I had a couple other patients but nothing super interesting. My 2nd patient is a 2 year old with RSV and my 3rd patient is a 4 month old with a urinary tract infection (UTI). They let me leave this afternoon at a decent hour and I have to be back early tomorrow morning to round on my patients and then present them to the residents. 

I guess I am back in action and although the break was extremely nice, it is also nice to be back in the hospitals.