I had hoped, foolishly I know but I had hoped that my sudden revelation this morning that I have a lecture entitiled Practical Eye Lab (bring your opthalmoscope!) on Friday despite the fact that my opthalmoscope is currently in Fort Wayne would be magically combined with another generous gift of time like yesterday's. Time, after all, is a valuable thing for a medical student to have, and it makes a lovely - if cumbersomely packaged - gift. This became adequately clear when I tried to schedule a doctor's appointment for a day when I could be in Fort Wayne to go to the doctor's.
Time was not to be mine today. The day began auspiciously in that our attending physician is brilliant, compassionate, funny and loves to teach; collided with two hours of lecture from twelve to two - even Lindy and Brendan commented that they had a difficult time staying awake, and I retreated to NetHack on my PocketPC in lieu of passing out from acute lack of concentrative skills half an hour into the second hour - and then spiralled rapidly out of control.
There were three patients to be seen when we arrived at the ER to meet up with LB, our resident. We split them up. I got the inpatient, went to see him. The case is really a perfunctory consult; young A is the three-month-old child of German Baptist parents, home for only two weeks of his life, now intubated secondary to aspiration pneumonia. Neurology comes in because he has an abnormal EEG. This is a boy, O Best Beloved, who is on phenobarbital at home because he had seizures in the NICU at an outside hospital. This is a boy, I repeat, on seizure control medications with an abnormal EEG that shows bitemporalal spikes, which means he's at risk for seizures. Why are we being consulted? To see if the apneic spells he was having might be seizure activity? Well, they might, but they might also be secondary to his pneumonia, and now he's on a ventilator anyway, which means we can't tell if he's still having apneic spells, so what are we going to do about it? To see if he's likely to have seizures? The EEG and his past medical history say he is. To find out whether or not the phenobarbital is the right medication for his seizures, if he's having them? Yes, yes it is. Great, could you consult anyway?
So I consulted. A's parents are well-read, polite, with hard questions for a medical student on her second day on the service. No, ma'am, we'd hesitate to call his particular EEG normal on any child; he's definitely at risk for seizures. No, sir, I don't know if he'll require medication the rest of his life. Yes, sir, they're likely to try and wean him off it as he grows older. Yes, sir, some children grow out of seizures. No, ma'am, we don't know if his apneic spells are seizures or not, and yes, ma'am, you may be right and they may be related to his reflux and pneumonia. But he's on a ventilator, it's hard to tell right now. The staff doctor? Dr. W. He's very good. The pediatric surgeons? They're top-notch. I worked with them a few months ago, and I like them. Yes, they have their quirks. No, I don't think there's a whole lot we're going to do as neurologists here, the most important thing for a baby like A is to have good long-term follow-up and I think you have that well under control.
This is a child like the children I saw in Pediatric Surgery; a former 29-weeker who weighed about three and a half pounds at birth and is still catching up (I need to get measurements tomorrow; I've been away from peds too long). He's spent three months of his 14-week extrauterine life in the NICU at another hospital, with all the horrible complications of prematurity it seems. He has low lung volumes. He's had necrotizing enterocolitis. He had group-B strep pneumonia and seizures and tracheolaryngeomalacia, which I think sometimes is something the doctors made up as a diagnosis because "swollen larynx" didn't sound complicated or frightening enough. And he was home for two weeks, with oxygen and a Sniff pillow and he was doing all right, until he aspirated. The heart breaks.
I wrote my note and brought it down to the ER to present to LB, then waited for the chance to staff. I was last in line.
I stopped in today, probably against all HIPPA regulations, to see an old patient of mine from Peds Surg. S is back in the hospital, has been for a month or more - I didn't go back far enough in his medical records to see - and he came up on my patient list from so very long ago, the list I didn't clear at the end of the last rotation at this hospital, came up as an inpatient and I had to wonder, enough to stop in and see him. He's still my darling S, all cupidsbow lips and round cheeks, a cherub of a baby with eyes whose whites have never been any shade but a pale goldenrod when I saw him. He didn't recognize me. I suppose it would be too much to expect that he would. But I may stop again; he's on the infant wing and I walk by his room every day.
The other two patients, the two in the ER, were up to be staffed first. The girl with the headache and slurred speech probably has a migraine, but we're going to work her up anyway to make sure we're not missing anything. We'll work her up as an outpatient, though. The other girl...she was the last patient of the day, because by the time we were done staffing her it was nearly 1800 hours. "I'm tired, my back hurts, and I have a headache," staff says. "Your patient isn't going anywhere, we'll staff him in the morning."
I think my headache was beginning then.
V has moyamoya syndrome, and bonus points to anyone who can tell me what moyamoya syndrome is, bonus bonus points if you can tell me why it's called such a ridiculous-sounding name. She's 12, no older than third grade mentally, and presented to the ER with a slightly-worse-than-usual weakness spell. This is a girl in whom nobody's quite sure what's going on or how to control it properly. We don't know if they're seizures, TIA's, psychogenic or what. But we're drawing a Dilantin level and adjusting, considering tricyclic antidepressants for her pain. What else is there to do?
The problem with patients like V, O Best Beloved, is that they are time-intensive. We spent nearly forty minutes in the room with her parents talking about all the things that might be going wrong and the ways that we simply can't diagnose them. And for those forty minutes, I had nothing to do but listen, try not to fidget, and concentrate on keeping track of what was going on. It was hard, O Best Beloved, so very very hard.
The ER exam room is a small cubicle of sterile white walls adorned with a smattering of cartoonish images of sports equipment and words like "football". Stars dot the empty spaces between, but randomly it seems. I look for a pattern. There is a sink set into a cabinet in the wall, a tiny baby-jail of a crib in the corner, bars extending well above the reach of any infant (failing a pituitary disorder) and shining with chrome. I lean against it, in the corner where the door meets the wall, and think about my back hurting. It always hurts at the end of the day. The voices flit into and out of my consciousness, mostly in, but there are too many things going on around me for me to successfully block out the distractions.
The room smells of two people who smoke a pack a day of cigarettes, enclosed in a doorless chamber for hours on end. The smell assaults me the moment the door is opened, and it sears the back of my throat as I breathe. In the corner directly ahead of me, above the head of the father - who refers to his wife as "Mom" and doesn't let her tell her own stories - is the television, originally tuned to Nickelodeon when we entered. He had reached up to turn it off and succeeded only in acquiring the ant-racing channel: dead static without sound, and the high-pitched and ear-drilling whine that only old-fashioned monitors and blank televisions can replicate. The sound, for forty minutes, bores into my mind. I tune in on it, tune out the rest of the world, try subtractive mental exercises to escape it. My feet twitch; I cannot go turn it off without stepping on the father. Forty minutes. My ears are still replicating the sound, five hours later.
She cannot get comfortable on her bed; her EKG wires wrap around behind her back and press into it. I see the solution to that, but I have already proved once that I am not paying attention to the conversation by helping her plug herself back in. And I shouldn't do things for her, it's more rewarding to her to figure them out herself. I can see that in her face, as she tugs the wires. I watch, catch hints of patterns and repetition in her motions, think through the mental gmynastic of untangling the three semi-braided wires hooked to electrodes on her chest. I can't help it; she is motion in a still room, fidgeting like I wish I could. And there is the pain of the TV whining for me to find a distracton.
On the far wall is a puzzle game for toddlers; four separate abstract tracks that are really the same pattern repeated and rotated and flipped. The four terminal coils, like lowercase e's, are a floral bundle in the center. Each track has four balls of each colour times five colours: red, orange, yellow, green, blue. Twenty balls. They slide along the tracks, which are straight with two branching squiggles on each side. The colours are random, in no particular order. It is behind the couple, and I work through the sorting of balls in my mind while I listen to the flow of conversation, looking in the right direction, seeking sufficient stimulation to keep my hands and feet locked where they are. Good student posture; I keep my hands folded behind my back, fingers twisting together, or I put them in the pockets of my white coat, where I keep change of at least three different sizes to sort. Idle hands make me anxious, and I am already on-edge as the whine of the television works its way down my spine, coiling into every muscle. I stand like a lady to defuse it, then like a model, trying on different subtle configurations of back and shoulders and the straightness of my knees.
It combines to keep me from yawning and shifting; I work alterations of the invisible muscles, I subtract and add sounds to my environment in an effot to block out the whine of the television, I sort change to keep my fingers from travelling over the items on the counter and fondling the cool smoothness of the baby-jail, I imagine in vivid detail the texture of the wooden balls in their tracks and the soft click and scrape they would make as they travel along the pathways I am mapping out for them. I imagine putting them in rainbow order, four and four and four and four and four, then re-sorting them by two's, then inverting the second half of the rainbow, two and two and two and two and four and two and two and two and two. And by ones, by three-and-one, forward and backward intertwining. I find some solace, sufficient stimulation to concentrate, in the patterning and the shifting of coins, and the forty minutes are at last over and I have heard - if not everything he said - at least enough that I understand the assessment and plan, and could probably repeat most of the talk if I were forced to.
I am also exhausted, glad for the offer when he tells us to go home, we'll staff my patient tomorrow. A's parents are going to ask all the same questions again; I could see in their eyes that they did not trust me, that I conveyed none of the confidence and knowledge they were seeking, hospital veterans that they are. I am experienced enough now, though, that this failure does not disenhearten me. Confidence will come.
Confidence will come, as I immerse myself in this fantastic opportunity. The Neurology service prides itself on teaching; we are given books and binders and articles filled with things to know and learn. I am not as frightened now as I was, planning it, and I have faith that I will pull through. But my head still echoes with the muscle-clenching noise of a dead channel on a television, and I can still smell used cigarettes, and there are soft clicks and rearranging patterns almost tangible at my fingertips, and it is long past time to submerge myself in unconsciousness again and sleep until perhaps I have forgotten it once more.
The alcohol scrub makes my hands smell like surgical gloves.