18 June 2012

The day my dog was fat

So I got in the elevator one day on my way to work. 

It stopped and picked up an older gentleman on the way down who greeted me kindly, so I decided to return conversation. I asked if he was going somewhere exciting. He said work, and he loves work. I asked of he worked downtown, since most people who live downtown with us also work downtown.  He said no, he works in Richardson.  Then he asked me of I knew what ideology was.

I thought a few moments, silently wracking my brain for what the word ideology could mean, but came up with nothing so I said no.

"It's the study of how the body hears"

"oh! Audiology" I said, "that's really cool."

He just smiled and we got off the elevator.  Which is probably a good thing because I would have either made myself look like a really big idiot if I told him I was a pediatrician who didn't know what an audiologist was.  Or I would have talked about how I just didn't hear him very well, at which point, he might suggest I get my ears checked.


But, nothing was said, which is probably for the better.

And, as if to remind myself of how silly I felt, my first patient of the morning needed a referral to an audiologist.  

At which point I just smiled.  

And thought of ideology.


I get tons of call backs from the pharmacy, usually asking to substitute a drug or checking on the dosage I wrote for.  

But last week I got a call to explain what the "l" [lowercase L] I wrote in my prescription was for.  I pulled up the electronic prescription I sent, and couldn't find an "l" in it at all.  The pharmacist, said:

"yeah, it's there right in front of the 2.  you wrote 'use every "l" 2 hours' "

I'm pretty sure that's a "1" not an "l."

I can see how similar they look.  The number one and the lowercase letter L.  But no, it says "Use every 12 hours, not every l 2 hours"

Deep breath.  No laughing.

Move on with the day.

I'm not the only silly one.


One day, I took my dog to the vet.  It was just for his yearly exam, he got a blood test, a poo test, and updated his shots.

I kinda felt like a proud momma taking her little boy in for his 2 year old well-check.  He just hit 2 years old, and stopped really growing fully.  He is eating better and he finally doesn't look like a sack of bones.  He behaved so well, he didn't even cry for his shots.


He was very nice to the nurse and the vet.

But the vet told me he was fat.  He has gained 6 lbs in the past year.  He got a bit taller too!

I couldn't believe what she was saying.  MY dog can't be fat.  Look how skinny he looks compared to the other dogs.  He runs and plays.





Which is the same "denial" phase a lot of my parents go through when I tell them their kids are actually fat.  Only they say: "No, they're the skinniest kid at school.  Every other kid is fatter than my kid."  And I have to remind mom that even though her kid is the skinniest, he is still fat.  It's just that all the other kids are even fatter.

So now, I'm feeling like a horrible parent.

How did I let my precious kid get fat?  I just wanted to make sure he was well-fed.  He was all skin and bones when I rescued him.  I gave him a full bowl of food every day.  And recently we've been measuring his feedings, making sure we don't give him too much.

Yet, he is still fat.

Oh, poor dog.

So then I tried to rationalize with the vet.  "We only feed him 2 cups a day, is that too much?!"

The vet said her 65 lb dog eats 3 cups a day.  And that my now 27lb dog is less than half her dog's weight so he should eat less than half her dog's food.

She said try him on 1 cup a day and then adjust it if necessary.

One. Cup. A. Day?

Poor fat dog is now on a diet.

And I feel like it's cruel.  I keep wanting to slip him treats and extra food to make sure he isn't starving. (although I don't, because I know better)  This must be why all the moms at my clinic still let their kid eat chips and sodas and ice cream.  They feel bad about their kids not being allowed to eat chips AND french fries at every meal, so they slip them more snack food so they don't starve to death.

And finally, I realize how hard it is to be the mom of a fat kid.

They're your precious baby.  And yes, they need to lose weight so they don't run into health risks.  But they're your only kid.  You don't want to have to starve them.  You don't want to have to deal with this "diet thing."  You don't want your kid to have to be hungry.

Every day, even when I'm not at work, I learn more and more about how to be a better pediatrician.

It's a hard balance.

I should start reminding my parents they're not horrible parents just because their kids are fat.



Some days I just have really bad, difficult parents.  

My favorite kind of difficult parents are the ones that are only difficult because they are mildly ridiculous.  Like the mom that cusses 8 times during the visit, then when I'm about to leave tells me that her son has the "worst behavior she's ever seen."

"See look, look at how he be crossin' his arms right now and givin' you a mean look, that's not normal for an 18 month old, is it?"

"Well," I start, "He must pick up behavior somewhere, Maybe you can think of someone at home that acts like that, that crosses their arms, maybe someone he looks up to..."

Mom just crosses her arms and says "I can't think of a single person that do that.  He's always around people that are real nice, people that would be good influences on him and all."

Well, I don't know.

What do you want me to tell you?!


Or another mom, that is yelling at her 6 month old, that she hasn't fed in 6 hours, to stop crying as we try to talk about her 3 year old.

She is worried because he won't let her potty train him.

At the same time, her 2 year old, (born in the same year! Irish twins!) crashes into the 7 year old and starts screaming, and the 4 year old whines in the corner.

You seam to have a lot on your hands, maybe it would be easier to leave some of the kids at home and we can just focus on your 3 year old.

She stops listening to yell at all of her kids to shut up so she can listen to me, and then asks me to repeat myself.

Perfect, this is going really well.  I can tell already, that this mom is going to be receptive to 100% of the things I tell her to try today...

She's one of those parents I give very specific instructions to, then make a print out of those instructions, so she can take maximum impact of all the things I try to tell her about potty training, like "stop liquids after dinner time" or "go potty twice before bed to ensure his bladder is completely empty."

She takes my printout and hands it to her 2 year old to appease him, who immediately sticks it in his mouth.

Mmmmm.  Tasty printer ink.

I can see that I'm getting no where with this mom.  I can't even communicate with her because of the circus of children clambering around the room.  She then yells at everyone to be quiet again while she abandons talking about potty training and focuses on how terrible her children are.

They won't listen to her at all.

Really?  They seem to be such perfect angels, I couldn't tell.

I cautiously suggest parenting classes, how they could be a good resource for her, to which she responds that she has already been to 2 classes, and they did no good.


I don't exactly know what she thinks I can tell her during her visit that would possibly help her out more than an entire parenting class.

She finally gets fed up of all the screaming that she says she'll try my tips and come back.

I can hardly wait to see her again.


But then some days I have the parents that are downright mean.  These are the worst kind of difficult parent I see.

Thankfully, I don't have to deal with many of these.

On occasion I have parents that yell at me because they want antibiotics and I don't think they're necessary.

Or parents that tell me my Spanish is terrible.

(To which I always want to reply that their English is equally terrible and at least I'm TRYING to learn a language that isn't the official language of the country I live in, and they're not even doing that, but I politely hold my tongue.)

And once, for the very first time this week, I had a parent that flat out refused to see me.

I walked in, she looked at me, and asked if I speak Spanish.  Most parents are so thankful that I speak Spanish, they don't care how many verbs aren't conjugated correctly.  But this lady, without hearing me speak more than 2 words, flat out refuses to see me.

She tells her oldest daughter, in Spanish, to tell me to leave and get another doctor because I don't look like I can help her.

I reply to her in Spanish, that I understood her perfectly, and I can speak enough Spanish to do a full exam and there aren't any other doctors at the office anymore because it's past 5 pm.  She tells me to leave, and to get someone else.

Because I don't look like I can speak well enough.

I leave the room, letting the door slam behind me just before the tears start to fall.

Can she not see how hard I'm trying?

Does she really think just because I'm white and I can't roll my RRRs that I can't help her child?

Thankfully, one of my Hispanic co-workers is still in her office charting.  She sees my face and asks what is wrong.  I told her how the patient refused to see me because I'm not Hispanic, and I can't speak Spanish fluently.

She gets mad at first, telling me how she's going to tell the lady off, and then she just takes a deep breath and tells me it'll be ok.

Some people are just like that.  They just want to have someone of their own race to see them.  And no matter how good I am, or how good my Spanish gets, it won't change the fact that I'm not Hispanic.  And that's ok.  Because I'm still a great PA.

I finally wipe up all my tears as my co-worker goes to see the patient.


I've decided there isn't much I can do to change a bad parent, especially in one office visit.

But I can still be the best PA I can.


Most people are private about their private parts.

They keep them covered by not one, but two layers of clothes.

Some don't.

In the office, so far, I've seen kids that refuse to wear underwear (usually a 3 or 4 year old little boy) and girls that wear shorts and underwear beneath their pants (usually they're girls who play volleyball or soccer).  I've seen my fair share of 15 year old boys who are so embarrassed to drop their pants for a well-child check.  

But sometimes I see weird stuff.

Like the grandmother of two teenagers who came in for well child checks.  I told younger sister to cover her eyes while I checked her brother's private parts.  But before I could do anything grandma says, 

"Oh, Honey!  We don't hide nothin' in this family."

Now, what am I supposed to say to that?  

So I just said "Oh, ok," and kept moving.

Poor kids.

And my favorite thus far:  The 6 year old who came in with "a rash inside his privates."  Now, I'm thinking, with all my knowledge of anatomy, that it would be awfully hard to see inside his privates.  But thankfully, once I get into the room, I see that it's a rash on the outside of his privates.  And mom is pretty sure it's just bug bites.

Yes, bites with an S.

As in multiple.

Poor kid.  Not only does he have bites, in an uncomfortable area, but now he has to show his privates to multiple people, just to get some treatment.  

Thankfully, we got him taken care of.

All the more reason to advocate bug spray.


And now the fun part:

Events in the past 2 weeks:

Awesome party at the newly-refinished Team Armstrong house.  They promised us a ping-pong table.  When we showed up, we had multiple pieces of a table that had bested the Armstrong family.  But the architects got together, and 2 hours later we had a completed folding ping-pong table!  Fun night :)

Brothers.  Happy to see each other.  Looking at the camera because they thought I had a treat in my hand...

We took the puppies to White Rock Lake.  At Sunset.

But mom, I don't wanna go home!!  They had so much fun romping in the water!

Setting up for a few house guests!  We had 10 people in our little apartment! Lots of Chicken Salad!

So, first I got my hair cut.  

And since I was feeling all fancy, I decided to go to Nieman Marcus to go dress shopping for a wedding I have the first weekend in August.  

Then I looked at the price tags and decided I was shopping in the wrong place.  So I took a picture of me in my second-favorite dress.  I was afraid if I looked at a picture of me in my favorite dress I would lust for it.

He knows how much I love to match.  We went shopping at Bed, Bath, and Beyond to use up our final stack of gift cards.  Cutest. Couple. Award.

Date-night Sushi!

03 June 2012

The day I got a reality check

I always mess up the first patient of the day.  Its gotten to where I think I need a practice round before I see a real patient, because something inevitably makes me second-guess my ability to practice medicine.

This day I forgot my stethoscope, which happens about once a week.  Not to fear, I've worked out a wonderful excuse that doesn't make me look like an idiot:  I ask a few questions and then slip them the line:

"Let me go wash my hands and grab my stethoscope and I'll be right back to take a good look at you."

Which usually works like a charm.  This gives me a chance to get my stethoscope, figure out what on earth is wrong with my patient, wash my hands, and enter the patient's room with a newfound confidence so I can get them to believe I know what I'm doing.  

It's brilliant.

And it really worked out well for me last Monday, because the girl had a strange circular rash, and I had NO clue what it was.  So I used the time to find my stethoscope as the perfect excuse to do some research.

And by research, I mean talk to my supervising physician, Dr. V, and figure out what the heck this rash was.

I walked into Dr. V's office and asked him about this rash.  The patient was 4 years old and she has a diffuse, well circumscribed, circular rash on her body that began 3 days ago.  I told him it didn't look anything like tinea corporis (ringworm, which is typically what any well circumscribed, circular rash is), and if I had to guess, the rash looked like a burn from a cigarette, only larger.  He smiled, and without even looking at the girl, told me it was Impetigo.

No way, I thought.

Impetigo is classically described as having "honey-colored crusts." And this rash looked like a burn.  I was a bit confused.

picture borrowed from: http://doctorgrasshopper.files.wordpress.com/2010/06/impetigo.jpg

Sensing my confusion, he got out his famous rash book.  I've seen this book several times, and frequently used it as a resource when a parent doesn't believe my rash diagnosis.  And here I am, being the unbelieving person as Dr. V opens his book.

picture borrowed from: http://lagunaskincenter.com/wp-content/uploads/bullous-impetigo1.jpg

And there, on the page in front of me, is several pictures of Impetigo, with honey colored crusts, and also with red, circular, burn-appearing rashes.  

I suppose that teaches me to doubt my supervising physician.

So, I went back into my room, took a listen to my patient's heart and lungs, took a "better look at her rash"  and promptly diagnosed her with Impetigo, which is a fancy way to say "staph infection."  I got her some antibiotics, and got her on her way.  


On occasion I'm super hard on my patients.  I expect them (well, I expect their parents) to actually have some knowledge of basic common sense.

But I really do get to see some crazy stuff.  

Crazy Stupid Stuff:


This mom brings her 2 week old son in for a check up.  She also has her 2 year old daughter with her for a "sick visit."  In the "sick visit" she wants to talk about how her 2 year old throws temper tantrums and destroys things and will not obey her.  Exacerbating the problem is her mother, the child's grandmother, who watches her daughter during the day and will not remain consistent with discipline.  I talk to her about temper tantrums, print her out a handout, and discuss the importance of consistency.  Then I take a look at her baby brother, who has a few problems and needs to get blood drawn.

Her baby brother screams his head off, which makes her scream her head off too.

Pretty normal.

But then I turn around to witness her having chewed the cover off of one of my board books that my sweet mother-in-law had sent to me for my patients to read.

SHE CHEWED THE COVER OFF OF A BOOK! That's not an easy thing for a 2 year old to do.  Not to mention her mom just stood there and watched her.

Maybe this kid has more trouble with her temper than I gave her credit for...

She ate my favorite book though.  Which is sad because books keep disappearing.  My super cool stickers are helping keep some around, but if anyone finds some old board books, I'd love donations!


Another mom, at the end of the visit after I have handed her the prescriptions for her child, asked me about the x-rays in the dentist office.

In Spanish.

She asked if the x-rays were safe because her child had 3 x-rays of his teeth last month to check for cavities and they made him wear a lead vest (good thing we routinely do lead tests so I knew the word for lead in Spanish!!) but the lead vest didn't cover his head.

She was concerned he would have brain damage from the x-rays.

Deep Breath.

I explained that his head would be safe, that one x-ray is equivalent to one day of sunshine, and that it wasn't enough to harm her son at all.

But that didn't satisfy her.  If the x-rays were really safe, why did he even have to wear a lead vest in the first place.  I explained to her that the dentist didn't know how many x-rays her child has had that month, and that he could have received other x-rays to check for broken bones, so the dentist wanted to protect him just in case.

Which just drew the question: "if the dentist wants to protect his body, why doesn't he need to protect his brain."

I don't know.  I'm not a dentist.  And now my brain hurts.  I only have so many words in Spanish.

After assuring her that many kids get teeth x-rays and they all turned out to be perfectly normal people, she was satisfied and left, finally letting me move on to do other doctorish things, like eating lunch.  At lunch, I asked Ana, one of my colleagues, what she would have said to the patient.  Ana told me that the body is squishy and needs protection.  But the brain is protected by the skull, which prevents harm from x-rays.

Much, much easier. 

Now I know what to say to the next concerned mother...


One Tuesday night I was on call, and I got paged by this mother that was super concerned about her 10 year old's fever.  She had given her daughter ibuprofen (the generic name for Motrin or Advil) and her fever had come back 3 hours later.  

(I just wrote you the abbreviated version.  The mom went into a 20 minute discussion about how her daughter had eaten a hot dog for lunch the day before and then she had a fever at school this morning and mom picked her up but didn't think she needed to take her to the doctor and how now her breath was "that sour breath" you get when you're really sick and how she wasn't sure if she should take her to the emergency room now because her fever came back so quick and she had sour breath...)

After asking specific questions and discerning that her daughter was going to be fine at home, I reassured her mother and told mom to bring her to the office in the morning.  Mom wanted to know about her daughter's fever.

I explained how she could alternate ibuprofen and acetaminophen (the generic name for Tylenol, assuming mom would know what that was because she used the generic name ibuprofen earlier) every 3 hours.  Mom had never heard of this before, so I broke it down and explained it to her.  I often explain this in the office and write it down because it is a bit complex.  This mom understood it, but had never heard of acetaminophen before.

She asked me to spell it for her.


She repeated back "A-C-E-T-E" before I could finish.

No, no, A-C-E-T-A-M-I-N...

It took us at least 5 minutes to get her the correct spelling.

I should have just said Tylenol.  Maybe I'm the stupid one in this scenario...

I assured her that the pharmacist could help her find the correct medicine over the counter at the store and dosage for her child and her age/weight.

Mom hangs up, and I give myself a huge pat on the back for educating someone and giving her the power to control her daughter's fever in the future.

Not 20 minutes later I got paged by the same mom again. With this question:

"The pharmacist told me I could alternate the ibuprofen and acetaminophen every 3 hours to control my daughter's fever, is that right"


I thought I just told you the same thing minutes before I spelled out the name of the drug for you.

Yes.  That is correct.  Can I help you with anything else tonight?  

No, thank you.  See you tomorrow.

I sure hope so.


Last Thursday I had a mom who came in with her child, and before I went into the room, my MA (medical assistant) warned me about her.

It's never good when my MA has to warn me about someone before I go see them.

It usually means they're crazy.

She warned me that this mom wanted me to check her son for leukemia.  I asked her if she meant anemia, which is pretty common among kids who only eat chicken fingers and drink soda.

But no, this mom was legitimately concerned her son had leukemia.  Well, in all fairness, it was her grandson; her daughter had leukemia.

But she wasn't concerned because he was acting strange or had any signs or symptoms of leukemia.  He wasn't bruised or tired.  He just had a cold.  So they went to the ER.  The ER took bloodwork for his cold (Anyone wonder why health insurance is SO expensive...which is another topic completely) and his platelets came back low, and then they took his bloodwork again and it came back normal.  They reassured her, but not enough I guess.

And now she's concerned.

For reassurance  I ran more bloodwork, which I assured her would most likely be normal.

And thankfully, it was.

I reviewed signs and symptoms of leukemia with her and told her things to look out for and made sure she was fully educated on all things leukemia and that she knew she could always call us for advice if she had any other concerns.

Which placated her.

And made me feel good about my job.


Going to the doctor myself made me realize I need to be more compassionate to my moms.  After all, most of them haven't been moms before, and the first time you do something, it's really scary.  

(We just won't mention, a lot of them are super young grandparents taking care of their children's child, which makes me wonder if there is any hope for the kid their raising to have a normal life since it's their second chance at raising a kid into a real, legitimate person....)


Life in the past two weeks:

At Travis and Kymberli's wedding.  Ryan was a groomsman.

The flash storm on Memorial day (notice the Patriotic colors!) That made us pull all the furnature off the terrace into the living room creating quite the puddle... 

Scrubby enjoying a car ride to a puppy play date with some of our friends that have a backyard.  He loved it! And we had yummy barbecue!