For most of the world (or, just the US), this weekend is a holiday weekend.  Monday off, lots of cookouts, roadtrips, seeing family, opening pools, etc, etc, etc.  For me, since this is study block, I don't really get to take weekends off let alone a LONG weekend.  But, I did take most of Saturday to go with some friends to Charlotte to see Wicked... and do various other fun things.  Maybe not a long weekend, but it was totally worth it!

So last year, a friend and I went to see Phantom of the Opera, and while we were there saw that Wicked would be coming in a year.  Fast forward a year... to now.  We bought tickets AS SOON as they went on sale and added a couple people to make a foursome.  Off we went to Charlotte yesterday afternoon to see Wicked.

Eating before the show is critical, so we decided to go to an Ethiopian restaurant because there are none in Winston, and one of the girls has been to Ethipoia and loves the food, and another is going in a few weeks and we thought it would be good to give her a little practice eating with her hands.  For those of you who have never had Ethiopian cuisine, I highly recommend you stop reading right now and google the closest place you can get it.  It's delish.  All the dishes are served atop injera, a flat sourdough type bread that is used to scoop up the entrees.  No utensils are used.  We shared a lab dish, a chick pea dish, and a sampler (which had everything!)...  I would have taken a picture, but we ate it all before I could even think about it.  Sorry.

After dinner, we decided to head downtown to find coffee.  We were yawning, and that was just not ok.  Note to you:  Do NOT go to downtown Charlotte the weekend of the NASCAR Coca-Cola 600.  Most of the streets were shut down, they were handing out free cereal in the streets, there were cops on every corner, and to top it all off, they opened the new NASCAR hall of fame two weeks ago and that was bringing race fans in from the speedway to the city.  I think they made all the businesses in the whole freakin' city close early because we could not find coffee ANYWHERE.  We walked a lot though.  And paid $5 to park.  Coffee = fail.

Then we went to the theater, which happened to be located next to the Bojangles Colliseum.  Another note to you.  No major event center should be named after Bojangles.  Anyway, as we parked and we walking in, we noticed a fire truck and ambulance outside and everyone outside the bulding.  Bad start.  Turns out an old man had apparently fallen going to his seat :(  I hope they give him a free ticket.

Fast foward to the show... AMAZING!!!!  In college Sarah played a couple of the songs from the sound track a lot, and they really didn't make any sense to me.  Now they do.  And I think I listened to the sound track about 6 times in Starbucks studying today.  I may or may not have been singing outloud accidentally....

But really, the show was incredible.  I would see it again tomorrow if I could.  The girl who played Elphava had an amazing rich voice and was simply fantastic.  Everyone was.  It was the best show I've ever seen.  And now I need to rewatch The Wizard of Oz with new eyes....

After the show, and since we'd eaten dinner early, we HAD to stop at Cookout (at midnight) for milkshakes and associated delicious food.  It was an excellent end to an excellent evening.  And along the way somewhere we decided to start an weekly international food dinner.  So, look out for posts about Perogie, Chicken Paprikash, curry, and whatever else we decide to make!

Hope everyone else had a great weekend!  And I suppose for most of you, it's not over yet....

Lucky.

In other news, I can now run/cycle/do anything without restriction!  You may recall my Being A Patient Sucks post about my tragic intramural soccer injury.  Since then I have been pretty limited in the activity I can do by pain and the logical assumption that if it's all busted up inside (which it is), and it hurts, I probably am making it worse.  I went to see orthopedics yesterday, and he said give it another 6 weeks at full activity.  If it's still giving me problems then, we will probably scope it and consider fixing the cartilage lesion that's probably the source of my pain.  So while it still hurts to do most things, I can go as hard as I can and see if it gets better or worse, with the theory being if's it's not good enough for me at maximum activity, it's just not good enough.  I still get frustrated that the pain hasn't gone away, but at least I have an end point now, and a reason to push it rather than a reason to baby it.  Hellooooo, running!  How I've missed you. 

Until next time...
Kari

So I am in my "study month" right now.  We are given 4 weeks off to study for the USMLE Step 2 exam, the second in a series of three board exams required to become licensed as a physician.  I've come up with a pretty good schedule to get in about 10 hours of studying a day plus all the other stuff I like to do.

Wake up
Get dressed
Eat breakfast/watch a few minutes of the Today Show
Go to starbucks and study all morning
Go to the gym, go home and eat lunch, shower
Go back to starbucks and study all afternoon
Go home and eat dinner
Watch TV/Read/Study more/see friends
Go to bed
Wake up and do it again.

It's about the same schedule I used a couple years ago when I studied for Step 1, and it seemed to work out well.  And then there is Wyatt....  His schedule is different

Sleep.
Sleep.
Scratch at the windows.
Sleep.
Get excited because Kari's home!  Oh wait, she's leaving.
Play with straws.
Play with milk tabs
Sleep.
Kari's home again!  Eat dinner.
Run around like a crazy man.  Maybe go outside and chase bugs.
Run around more.  Maybe attack a bee.  Dive under the couch. 
Play with milk tabs
At 3;00AM, it's time for breakfast.  Smack Kari in the face.
Scratch at the Bulletin board.
Knock books on the floor.
Breakfast!
Now I'll sleep.

I have this nasty habit of buy books every time I walk into a bookstore... even when I have a stack of them at home I haven't read.  So I'm making it my goal to work through all the books I've bought but not read.  I'm already two down, but there are many more to go!  The rules are simple.  Read the books I have before buying more.  I can't buy a new book until I've read an old one, and the new one goes at the end of the stack.  You can keep track of my progress on the left hand column.  If there are books you think I should add to my list, let me know!

Cheers,
Kari

Yesterday was my last day on the PICU.  I ended the month with mixed emotions.  There were some very hard days throughout the rotation, where it seemed like parts of critical care were futile, that we were fighting a losing battle with technology that only delayed death.  But there were days, and patients, where we saw it work, and saw kids who otherwise would have died, get better. 

There was one little girl who was already in the PICU when I arrived last month.  She was just over a month old, and had spent her entire life in the hospital.  She was born with a congenital heart malformation called Tetrology of Fallot (tetrology meaning four specific malformations, Fallot being the guy who got to name it).  Because of the severity of her malformation, she underwent surgical correction within a few days of birth.  Following her surgery, she went into cardiac arrest and required CPR.  This lead to kidney failure, and she needed dialysis.  She became extremely swollen, gaining almost twice her body weight in fluid distributed throughout all her tissues.  When I came on service, they were trying to figure out WHY she was so swollen and how to make it go away.  For weeks, they'd made no progress.  In addition to the swelling and renal failure, she had an open chest wound because after her heart surgery they were unable to close the skin and tissue over her sternum because of the swelling.  This open incision was covered with a wound vac and could not be closed until the swelling went down.

For the first two weeks or so I was on service, we seemed to make little progress.  Her kidneys didn't work so dialysis was the only way to get fluid off.  We cut down the amount we gave her between medications and feedings, but it didn't seem to help.  She had profuse diarrhea and was becoming malnourished, but nothing seemed to stop it.  She was on a ventillator because she couldn't expand her lungs with the pressure in her chest from extra fluid, and we couldn't wean it at all over those two weeks.  For the first week I was there, we were pretty sure she wasn't going to make it.

But we kept tweaking medications, and gave her a little time.  About the beginning of my third week, she started making urine again, a symbol that her kidneys might be starting to work again.  Her diarrhea slowed down.  She was negative for the first day ever (negative meaning she lost more fluid that she gained in a day).  She lost a little weight.  And day after day, she got a little better.  Some days were not good, and she made no progress or backslid a little.  But overall she continued to improve.  I called her the little biggest loser baby, losing weight each day to get back to her normal weight.  This week we were able to send her to the OR to have the incision on her chest closed. 

She was still on the ventillator when I left Friday, still getting dialysis to help remove fluid.  She was far from ready to go home, and not out of the woods.  But she went from probably dying at the beginning of my time in the PICU, to probably going to be ok at the end. 

So, 1 4th year rotation down and 11 to go.  I think it's going to fly!  Next up is study month.  I will spend 4 weeks making my own schedule, studying for 8-10 hours a day and doing something with the others.  I won't have interesting stories to share... well, I will.  But they won't have anything to do with the hospital.  On June 11th, I take Step 2: Clinical Knowledge.  And then I go on vacation.

Until next time,
Kari

Friday was another one of those days... like the one that prompted PICU Lesson #1, the one that really inspired the revival of this blog. 

On Thursday night before I went home, we got a call from a hospital on the west side of the state saying that they had a 4 year old with what they thought was Hemolytic Uremic Syndrome (HUS).  They could not provide dialysis to treat his kidney failure, so they wanted to transfer him to us for better care.  When I left, they were heading out to pick him up and bring him back, something around a 4 hour trip.  I would pick him up as my patient when I came in in the morning.

When I got in Friday morning around 6:45, I got right to looking up what had happened with him since he'd come in overnight.  Throughout the morning as we were "prerounding" on our patients (going around and examining all the patients, getting their vital signs, seeing what happened overnight), he had a couple episodes of worsening blood pressure and unstable heart rate.  By the time we'd finished prerounding and were ready to round (seeing all the patients AGAIN as a whole team and making decisions for the day), he'd been seen by infectious disease also, because we were very much concerned that what he had was NOT HUS, but Rocky Mountain Spotted Fever.

When I presented this patient to the team, this 4 year old little boy who'd been healthy the week before, this is what I had to say:

When he was sent from the outside hospital yesterday, he came already on two pressors, medications to keep his blood pressure high enough to get blood to his body.  He'd recieved many liters of fluid.  He was on Vancomycin, Rocephin, and Doxycycline, three different antibiotics.  When he arrived here, he was intubated without sedation.  His blood pressure was dangerously low and he was started on another pressor, making the total three.  We considered bypassing his heart and lungs and putting him on ECMO (extracorporeal membrane oxygenation), but he was too sick for even that.  His infection had spread throughout his body, causing his capillaries to leak fluid into his tissues and causing swelling all over his body.  It also caused bleeding, which showed itself with a purpuric rash all over his legs, arms, torso, back, and neck.  He was bleeding out of his nose, his endotrachial tube, and his bladder catheter.  He also had blood in his belly, chest, around his heart, and possible in his head.  His feet were white and cold with no pulses.  His right hand was black, tense, and necrotic.  His kidneys were failing.  His liver enzymes were elevated, evidence that his liver cells were dying and releasing toxins into his blood.  He'd received over 5 liters of IV fluids, 4 units of blood, 4 units of platelets, 4 units of fresh frozen plasma, and 2 units of cryoprecipitate, all in an effort to keep his blood volume up... to no avail.  There was not an inch of this child that looked normal.  He was the sickest human being I have ever seen. 

His disease, presumably Rocky Mountain Spotted, raged through his body causing disseminated intravascular coagulation, multisystem organ failure, and irreversible septic shock.  He did not have a single organ system that was unaffected.  They say that each failing organ system gives you a 20% chance of dying.  Kidney, liver, heart, lungs, skin, brain.  He had at least 6.  That's a 120% chance of dying.  Despite our efforts, which were swift, sincere, and vast, there was nothing we could do.  One of the neurologists came down and we performed an exam that revealed no brain activity.  At that point, there was nothing left to save.  His parents, who from the beginning said they did not want him to suffer, quickly said they wanted to withdraw care.  They cut a lock of his hair from his head.  A priest came and blessed him, anointed him with oil.  His mother held him.  His father couldn't bear to see his son, now bleeding and bloated, looking nothing like the child he'd raised and loved.  When we disconnected the ventillator, it only took two minutes for him to be gone.  He had notihng left to fight with. 

Our team was devastated by his death.  Not only because we couldn't save him, but because a week ago, he could have been saved.  He didn't have to die.  The week before, he'd gotten a fever and his mother had taken him to the ER.  They sent him home, calling it a virus.  The next day, his fever was higher, and his mother took him back.  They sent him home again.  Later in the day, he developed a rash on his feet and still had the fever.  His mother knew something was wrong, and took him back.  They gave him amoxicillin and sent him home.  Wednesday (two days before he died), he was still not feeling well, he still had the fever, and his mom sensed something was wrong.  She got a ride to another hospital, where they gave him a shot of antibiotic and admitted him to the hospital to investigate.  Within hours, he'd become lethargic, hypotensive, and very very sick.  They intubated him, gave him fluids, tried to stabilize him, and on Thursday decided they needed help.  You know the story from there.

Now, if you're from North Carolina, you've heard of Rocky Mountain Spotted Fever.  It's transmitted through tick bites, although frequently you never see the tick.  It presents with fever, headache, and a rash that usually starts on the feet and hands.  In North Carolina, if you see a patient with fever, rash, and headache, it's RMSF until proven otherwise, and you treat with Doxycycline.  If you treat within the first 4 days, virtually everyone is fine.  If you wait, there's no guarantee.  If untreated, RMSF kills about 20% of its victims.  This young boy did not receive treatment at the first hospital he was seen at.  I was not there and I don't know what they saw or what they were told.  I can't say for sure that they should have known to treat him for RMSF, but I know they didn't.  And if they had, he'd probably be alive today.  I'm sure the doctor who treated him knows that now.  And I'm sure, it's killing him inside that he didn't treat it.  But still, I can't help but think that he didn't have to die.

This will probably be one of those patients that changes my prescribing practices for the rest of my career.  I expect that it will do that for the other students, residents, and physicians who also treated this patient.  More kids that necessary might get doxycycline because of this boy.  But maybe, one will get treated who otherwise wouldn't have.   

Never shake a baby.  Should be obvious, right?  I could have titled this post "non-accidental trauma", the new politically correct term for child abuse.  But I didn't think it would get your attention in quite the same way.  This post has been brewing since I was on the general pediatrics service a couple months ago, but it became necessary when I met one of my PICU patients.

Here's quick run down of the patients I have seen who were getting the non-accidental trauma workup...
1. 6 month old girl with fractured femur
2. 6 month old girl with fractured femur (yes, a second one)
3. 3 year old boy with fractured humerus
4. 6 year old boy with bloody nose
5. 3 month old boy with rib fractures, seizures, brain hemorrhages, and blindness.

Of these 5 kids, one was ruled accidental (#1), one was ruled unlikely to happen again (#4), and the other three children were taken from their parents and put in DSS custody.  The worst case of all is the last, a 3 month old infant boy, totally normal and adorable and innocent.  The story from his parents is that he was sitting on the couch, and then rolled off.  Then they noticed he seemed to not be looking at them, and was shaking a bit.  Rolled off the couch.  Seriously.

First of all, three month olds can't roll.  Secondly, when the prodigious ones DO roll at three months, and they roll off the couch, they generally don't break ribs on BOTH sides of their chest.  This child came to the ED in status epilepticus (having constant seizures), with epidural hemorrhages, subdural hemorrhages, subarachnoid bleeding, retinal hemorrhages, and diffuse axonal injury to his brain.  Yes, that is all as bad as it sounds.  When I met him, the little guy was in a drug induced coma because it was the only way to stop him from seizing.  Even with three other medications, he continued to have abnormal brain activity.  When we decided that he was not going to stop seizing, we took him out of the coma to see what he would do.  He opens his eyes occasionally, although much of that is blinking rapidly, likely seizures.  He responds to pain, but nothing else.  He doesn't look at anyone, doesn't respond to his surroundings.  He is blind.  He can breath on his own, which I almost wish wasn't the case.  He has no hope of any rewarding life.  He is incapable of enjoying any pleasures of life.  He will not ever be a boy scout or go to school or see the sunrise or eat a popsicle or learn to tie his shoes.  He won't walk.  He won't talk.  He won't swallow. 

Last week, we took him off the ventilator to see if he would breath on his own.  Our hope was that the parents would agree to let him go if he didn't.  While they don't have custody of him, they maintain parental rights, which means they have the ultimate decision in withdrawing or withholding care.  They wanted him reintubated if he could not breath.  We haven't even addressed tube feeding or tracheostomy or who will care for him.  Taking care of a baby 24/7 doesn't seem like that big a task.  But taking care of a 17 year old with all the needs of an infant is an unimaginably difficult task. 

I imagine the mother will not withhold any care.  I don't know if that comes from guilt that she didn't keep this from happening (the father is suspected of being the abuser), or from fear that they will be charged with murder when he dies, or if they don't understand the severity of his condition.  Either way, I imagine he will live... if you can call it that.

The worst part of this, of all the non-accidental trauma cases, is that they are 100% totally preventable.  Abuse is never justified, never deserved, and never excusable.  Abuse of anyone, let along a child, is inexcusable.  If you know someone who is being abused, who is abusing, or who you think needs help, please go to one of the links below for help, or call your local police to report it.  No more children need to die at the hands of the adults that are supposed to love them.

Child Help
State Child Abuse Hotlines

One of the most important things I have done for myself through medical school is have a life. I know that sounds pretty straight forward, but it actually was a times a choice I had to decide to make. Get a better grade on this test, or do something I really love? Unlike some of my classmates, I chose to have a life. I'm not saying that was always the right choice. Sometimes I probably should have studied more. But, I didn't. And I've done fine. And I've had a life. This weekend was an excellent example of life, so I thought I would share!

On Friday, my friend Betsy's parents were down visitng from Michigan for mothers day weekend, so we all went out for a nice dinner at Old Salem Tavern downtown. It was a FANTASTIC meal with good company. Excellent start to the weekend.

Saturday morning I woke up early to drive to Boone with a friend and go hiking. There is this fantastic 5 mile trail near the Blue Ridge Parkway with beautiful scenery, varying terrain, and the weather was PERFECT! After the hike, we had some Chic-Fil-A for lunch (for those of you who haven't had it before, try it. It's delish), then went shopping for some work clothes. I always have great success at the Banana Republic outlet, and this was no different. Too much money and a big bag of clothes later, we forewent (is that a word) other outlets to get to the General Store in downtown Boone, where you can buy crogs, penny candy, and home made soap all in the same store... if you want. Except this was App State graduation weekend! Plan foiled. So we just went home instead.

Then I went back over to Betsy's to cook dinner for her parents. We made the classic favorite meal of cajun shrimp, sweet potato fries, and wilted spinach salad, with apple tarts for dessert. Again, delish. Then we watched The Time Travelers Wife... well, I watched about 20 minutes before falling asleep, but everyone else loved it! I woke up as it ended, went home, and went back to sleep.

Sunday... ohhh Sunday. It was MOTHER'S DAY!!!! So we made a Mother's Day breakfast of french toast with fresh berries and whipped cream, and coffee. Then Betsy's family had to leave so we waved goodbye, then went for a run to work off all the food we'd eaten in the last 48 hours. Then it was off to Salisbury for, you guessed it, more eating. We met a friend of mine at Catawba College for lunch, then drove back to Winston so I could get a new cell phone, and then it was off to Reynolda Gardens for some picture taking and general awesome-weather basking. Then we watched The Hurt Locker (excellent, I highly recommend it), and it was time for some sleep before starting another week in the PICU.

Nothing too spectacular... which is exactly why it was a fantastic weekend. Good friends, good food, good weather, and no studying. If only every weekend could be like that.....

I knew that being in the pediatric ICU for a month would probably mean there were some tough moments. No one likes to see people suffer, let alone children. But what I didn't anticipate was how quickly one of those tough moments would come.

Day 1 in the PICU. It was a Tuesday morning, and we were rounding at about 8AM when we got word from the ED that there were two car accident victims, 12 and 16 years old, sisters. They were on their way to school when they were hit while making a turn. The 16 year old was stable, but the 12 year old was critical. So we stopped rounds to prepare for the 12 year old to come up from the ED. In a whirlwind of activity, then prepared one of the bigger rooms for the new trauma patient, brought up blood and warm fluids, a crash cart, equipment for tubes and lines that would come out of every orifice of her body.

We were all assigned roles. I was the first to start chest compressions if her heart stopped... again. It had already stopped three times and they'd managed to get her back each time.

Her major injury was an open skull fracture. I'll save you the details, but when we looked at the CT of her head, we all knew it was most likely a non-survivable injury.

She came up very unstable, needing blood and fluids, chest tubes on each side because of collapsed lungs, arterial lines and venous lines and central lines. Surprisingly, she didn't code again. Her parents and step parents arrived and stayed at her side through many of these procedures. We talked to them about signing a DNR. We all decided not to escalate care if she started to go downhill again. No medicines to keep her blood pressure up. No CPR. If she went again, we would let her go. Her father, a 6'4", 300 lb man, sat holding her hand with his head down, and we could see the tears dripping off his nose and onto the floor, mixing with the blood of his youngest daughter.

When we'd done everything we could to stabilize her, everyone stepped back, took a deep breath, and we looked at the situation we were left with. She'd shown no signs of any brain activity. She didn't respond to pain. Her pupils were not reactive. She was not breathing on her own. The only thing left for us to do was warm her up. Her body temperature was 93 degrees, and in order really assess her brain function, she needed to be warmer. So over the next six hours or so, we worked to get her temp up. Once it reached an acceptable level, we did an official brain death exam. She had no response to any of the tests. Not surprisingly, but very tragically, she was definitevly determined to be brain dead.

We had a family meeting. Her parents didn't want her sister to be there at that time, so it was just the immediate family and their pastor. We told them we'd done everything we could, but she showed no signs of any brain activity. She was dead. Somehow, in the waiting room, her sister who had been driving the car, heard the news. We heard her screaming from our conference room. When she came in to see her parents, she collapsed and cried, "I did this to her, it's my fault, I killed her." Her parents insisted it was not her fault but their cries fell on deaf ears.

I left for the evening immediately after that family meeting. They still had the burden of deciding whether or not to donate their daughter's organs. When I came back the next morning, she was still there, still on all the same support she'd been on when I left the night before. The family had decided to donate her organs, and she was awaiting her trip to the OR. Her family was already gone though. They'd said goodbye to their daughter the night before, taken their other daughter home, and began their new and forever changed life without their baby girl.

When I went home after the family meeting, I sent a message to my own sister, who was celebrating her 21st birthday that day. I told her that I felt like I should tell her I loved her, in addition to happy birthday, and when she aked why I told her about my day. She told me to tell the sister, if I saw her again, that her sister knew how much she loved her, even if she didn't get to tell her. I didn't get to see her again, but I hope someone got to tell her that her sister knew she loved her.

So, today, tell someone you love them. Even if they already know. Because you don't know when you won't get to say it again.

The next PICU story won't be so depressing, I promise.

Until next time,
Kari

It's been almost two month's since my last post, which is unacceptable. Here's what's happened in the interval:

- I started and finished my pediatrics rotation, the last rotation of third year.
- I saw multiple children who were victims of "non-accidental trauma" or child abuse, the subject of a post soon to come.
- I started running and riding my bike again, albeit VERY slowly.
- Spring arrived!
- I cooked a LOT of dinners with my friend Betsy.
- I filled up my gas tank 5 times.
- I rewore a bridemaids dress for a different occasion (ALWAYS a big accomplishment!)
- I put sweet new blue bar tape on my bike (and it got it's yearly tune-up)
- I met my yearly deductible for my healthcare for the year...
- I bought a webcam and downloaded Skype so I can talk to friends across oceans.
- My little sister turned 21!
- I started my 4th (and final!) year of medical school!!!!!

I think that hits all the high points :) So, most importantly, I started my first rotation of 4th year in the Pediatric Intensive Care Unit. Tomorrow's post will give you the details of my first day. For now, I will give you the summary of the next year of my life, and say that I am EXTREMELY excited about it!

Kari's 4th year schedule

April-May : Peds ICU
May-June : Step 2 study block
June : Vacation in Michigan
June-July : Physical Medicine/Rehabilitation
July-August : Emergency Medicine
August-September : Othopedics (Trauma/Ankle)
September-October : Family Medicine
October-November : Burn Surgery
November-December : Campus Medicine @ WFU
December-January : Vacation/Interviews
January-February : Law in Medicine
February-March : Sports Medicine
March : MATCH DAY!!!
March-April : Community Medicine
April-May : Senior Seminar
May : GRADUATION!!!

And then, I'm a doctor. Watch for the stories that will unfold between now and then!

Cheers,
Kari