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.

A-C-E-T-A

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"

Really??

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....)

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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!