My Quarter-Life Crisis

16 05 2013

Hello again!  So much has happened in the past couple of months, but most of it has kept me quite busy to the point that I prioritized sleep over writing.  What can I say, I value sleep.

In that time, I have completed my emergency medicine clerkship, passed another semester of graduate coursework, took a weeklong vacation to visit friends out of town, have been working on a number of small side projects both academic and personal, began my last semester of classes ever, and had a small career crisis.

Career crisis indeed, because about 2/3 of the way through my EM clerkship, I was hit with the idea that I really could be happy as an emergency physician.  Hit is not really the right word, steamrollered really fits better.  I always thought it would be something I liked, but I was so swept up in the negative things I heard about EM from members of almost every other medical specialty that I convinced myself not to keep that option open.  I also had the dilemma of being so invested in pediatrics for the last year that I didn’t want to give all of that work—research into residencies, investment into pediatric volunteerism, not to mention having told everyone I met for the past year that I was going to be a pediatrician—to be flushed.

While that particular issue has not entirely resolve, one of my classmates assures me that this is supposed to get worse before it gets better.  Apparently for me, the doubts are coming in waves, because I was in the clear a couple of weeks ago and now still feel somewhat conflicted.  I know that this sort of career decision issue is more common than not among medical students, why should I be exempt from it?  Logically, this was bound to happen, but just because logic dictates a statistical likelihood does not mean that I have to like it.

The scariest aspect of this whole “quarter-life crisis” is that pediatrics and emergency medicine are very different specialties, and this dilemma points out that perhaps I am not as certain about where I want to end up in life as I had originally thought.  Everything will work out eventually, right?  So the tentative plan is to do some shadowing in Pediatric EM and see whether I should consider that as a valid career option, continue to pursue a residency in pediatrics, and investigate the dual certification programs (all 3 of them, 6 spots total nationwide.  Long-shot doesn’t even begin to cover it). The good news is that if you all stick around for another year, all of this will be resolved.

It’s nice to know that there’s an end in sight.

I thought you’d enjoy these cartoon diagrams of how to choose a specialty.  Both are entertaining–what can I say, I can still have a sense of humor about this.  Take a minute to enjoy:

specialties2

Specialty

Speaking of the light at the end of the tunnel, medical school graduation season is upon us.  It’s indescribably strange to think that very soon, all of my classmates—the ones I studied and partied with, rejoiced and complained with, struggled and succeeded with—will be gone.  Well, almost all of them; a handful will still graduate with me in a year for various reasons.  It’s a bizarre thought that is difficult to put into words.

I will post soon with a few more interesting stories about clinical encounters—you still like those, right?  I know, anecdotes and random funnies are much more of a draw than my own conflicted sort-of-4th-year medical student musings if you are not a family member or close friend.

Next time.





The AfterMatch

25 03 2013

The AfterMatch

If you know anyone in medical education, you know that Match Day occurred last Friday.  I wrote a post about Match Day last year that goes into more detail about the actual process of the NRMP Match, so I won’t insult your memories by describing it again.  If you are a newer follower of this blog, feel free to go back and read that post before continuing.

This year’s Match was particularly fun and exciting for me for 2 reasons.  First, I was genuinely excited for my matriculating classmates to discover where they would be continuing their medical training for the next 3-7 years.  Second, I will be matching next year, and it was really great to experience the excitement and energy of the day without the nausea and self-doubt that comes with going through the process yourself.  (If you forgot, I am taking an extra year for a graduate degree and will be matching next year rather than this year). 

It was as much fun as I had expected, and the vast majority of my classmates matched into their first-choice programs.  There were a handful of disappointments, as there generally are, but nothing major that I know of.  On that day, I felt so optimistic and energized for my own Match Day.

Then I started hearing disturbing things from the faculty involved in our area’s residency programs.  As it turned out, an astounding 1,100 US medical seniors did not match at all. They will all be graduating in a couple of months without jobs, unable to get a job in the medical field, and with about $200k in student loans that go into repayment next January.  The number last year was much lower, I’ve heard figures ranging from 100 to 850, but the jump was shocking for the faculty I spoke with.

Every year, students don’t match for a variety of reasons, and as bad as that number is, there were two numbers that scared me even more: 10 and 17.  Those were the numbers of positions in the country that each that pediatrics and internal medicine residency programs, respectively, had available to students at the time the SOAP (formerly known as the ‘scramble’) began. 

Let me explain why those numbers are frightening.  Typically, when medical students don’t match into a residency program in the General Match (and are subsequently forced to participate in the SOAP), it is because they are either poor students overall, or they are average/good students applying to programs that are out of their league.  This is typically seen in specialties like dermatology, ENT, plastic surgery, and orthopedic surgery.  It can also happen with the primary care specialties—which are considered to be less competitive—when the student only applies to programs like Harvard, Yale, and Boston University.  Having a fewer number of spots available at the SOAP for all pediatric programs indicates that there are other reasons, potentially more serious ones, for the 1,100 unmatched US graduates this year.

The most concerning issue to me is a political one.  Shocking, I know.  As much as I like President Obama, he’s made some pretty boneheaded decisions where medical education is concerned.  The ACA calls for a greater number of physicians in primary care practice, and so in the last 3-5 years, the government has authorized both the creation of new medical schools and expansion of class sizes at the existing ones.  At the same time, GME funding is on the chopping block and Medicare/Medicaid payments are being reduced even further.  Because this is how residency programs are funded, the numbers of slots in the training programs is dwindling.  One residency program in my general area went belly-up a couple of years ago.  Add that to the 80 hour workweek cap for residents, and working crazy hours for about the same wage as the cashier at Speedway isn’t enough of a bargain for hospitals anymore.  In this economy, hospital administrators are not likely to continue making choices that are not fiscally sound.

As medical students, we are told over and over again that there is a residency position available for every senior medical student.  Even though the NRMP’s website boasts more new residency positions than ever this year, US medical grads are falling through the cracks.  Why?  This country’s residency programs also accept international medical graduates to train with them, and even though they are supposed to give preference to the US grads, this may not be happening.  I can understand why program directors would want to do this.  In an increasingly litigious environment where the workweek is capped, I can see accepting a high-performing IMG (generally, these graduates are certified physicians in their own countries, often bringing years of experience to the table) over a low-performing, brand-spankin’-new US graduate.   

I came across an editorial piece on the web this past weekend that addresses many of the same issues (you can see it here: http://thehealthcareblog.com/blog/2013/03/18/health-care-by-the-numbers-what-the-early-2013-match-day-numbers-tell-us-about-where-were-going/). 

My eyes and ears are alert for news about why this happened to so many US medical graduates.  1,100 students will graduate this May/June with medical degrees and will not be qualified to do a single job in the healthcare field (except, perhaps, work for big pharma).  They will have no choice but to go into loan repayment early next year on an enormous sum of money without adequate sources of income.  And they will all be entering the Match with me next year along with graduating classes from newly established medical schools. 

Bottom line: this was a pretty painful reminder of the potential consequences if I do not manage to keep my nose to the grindstone in the next year.  So I will keep doing the best I can, cross my fingers, and hope for the best





Tales from the ED, Part 1

14 03 2013

Story time!  I promised in my previous post to relay some patient vignettes, so here they are.

The first story today centers around an older gentleman; we’ll call him “Ron.”  Ron originally came in for rectal bleeding, which is a fairly routine complaint.  What wasn’t routine was walking into his room to do a history and physical and see that he had a glaringly obvious erection.  I had to do a double-take but ultimately collected the H&P without acknowledging it.  After all, this sort of thing happens from time to time and most men are embarrassed by the lack of control over their bodies.  No biggie.

When I went back into the room 30 minutes later to do a rectal exam, Ron still had a boner with a hospital gown and sheet doing a very poor job of hiding it.  His wife and two adult children were still in the room, and none of them said a thing.  At that point, I was a little more concerned, but he didn’t bring it up even after his family had left the room.  In retrospect, I really should have asked him about that bit of wood, a simple “how long have you had that erection?” would have sufficed.  But hey, he didn’t seem worried about it.

In the bustle of the evening, Ron’s condition slipped my mind until his abdominal CT scan came back (yes, friends, almost all of the abdominal/gastrointestinal complaint patients I’ve seen have had CT scans).   There, on the computer screen, was a glaringly obvious erect penile prosthesis.  Being a medical student, I really should have thought of that sooner, but you live and learn.  A bit of Googling and several inappropriate pop-up ads later, I can say that I definitely learned something I hadn’t expected in Emergency Medicine.  Why he allowed the prosthesis to remain erect, however, remains a mystery.

penile

Story #2 pertains to a very nice older gentleman, “Rick,” with heart failure whose complaint was massive testicular swelling (a symptom not uncommon to men with heart failure).  I put on gloves and did a full history and physical exam.  Aside from having marked swelling from the feet up to the boys, he had a lot of scratch marks on his arm, including one area that looked infected and swollen to the size of a golf ball.  I started to ask him about them, when he spoke first.

“Hey, doc, could you grab that?”  He gestured toward his leg.  I turned and saw a little black dot moving down toward the foot of the bed.  Things like flies and spiders don’t bother me at all, and I reached into the nearby cupboard for a specimen cup to capture and later release the insect.  Except that once it was in the cup with the lid sealed, it was clear the insect wasn’t a fly or a spider, it wasn’t even a millipede or a louse.

“Yeah, I’ve got bedbugs really bad at my house,” Rick said nonchalantly.  At that point his torn-up arms and complete nonreactivity to harboring a stowaway on his body made sense.

I won’t lie, it was easily the most freaked-out I have ever been during a patient encounter.  It took a lot of self-control to smile and politely excuse myself with my critter friend in hand (shutting the door very tightly behind me) instead of jumping ten feet away from Rick and making a snide comment about how it would have been super if he had told anyone about the bedbugs when he first arrived.

In case you are wondering about the protocol, the patient’s room (they had put him in a trauma room) and the CT scanner which he’d been in (the main one) both were shut down, along with all of the equipment each contained, until the following morning when the hospital’s exterminators could deal with the potential infestation.  As for me, I changed my scrubs and finished the remaining 7 hours of my shift with the discomfort of psychosomatic itching all over my body.  Even though my shift finished at 2am, I took a very long shower the second I got home.

The third story is about a diabetic woman named “Anna” who came in originally because of self-reported hypoglycemia (low blood sugar).  When her sugar was checked at triage, it was in the 100’s, a perfectly fine level for a diabetic.  After telling me that she had a sugar in the 40’s earlier, I figured “great, problem solved, a little counseling and she can go home.”  Easy patient.  Before I had a chance to say anything, she said “I’m also pregnant.”

A few things didn’t make sense.  The most obvious was the negative urine pregnancy test collected when she was brought in.  She was also on a diabetes med that is terrible for pregnant women.  I didn’t want to act like I knew more about her health than she did, so I excused myself to look at her records again.

Anna had been to the ED 7 times in the previous 2 months for various complaints, each time receiving a pregnancy test (all negative), and had also had 2 ultrasounds and a CT scan that would have likely shown something.  One test was positive: an MRI from almost 2 years before, which showed a small tumor on her pituitary gland.  Her primary doc had charted that she had an elevated level of prolactin, which causes periods to stop and stimulates lactation.  Those symptoms had started in October, and no matter how many times her primary doctor, several emergency medicine staff members, and 2 OB/GYNs explained this, she still believed she was pregnant with a child that was conceived in October.

Eventually, after a few attempts at convincing her otherwise, the ED doc did what ED docs do best: get the patient out of the ED.  I have no idea how her story turned out—a theme of my rotation in the Emergency Department.





The Man Without a DVT

20 02 2013

My time in the ED is about a third of the way over at this point (one shift a week for 12 weeks), and I’m pleasantly surprised to find that I am truly enjoying my time there. 

I’d always thought that the lack of follow-up, not knowing whether my patient lived or died or what the final diagnosis was, would bother me.  It does.  The nice thing, though, is that I wouldn’t have to tolerate the endless frustrations of trying to manage patients with chronic illnesses who are relentlessly noncompliant with their treatment regimens.

Oh, sorry, non-adherent.  We aren’t supposed to say noncompliant anymore because it gives off too much of a negative connotation and implies that these patients are bad people, or some such nonsense.  Really, the terms mean the same thing and I think we should just call a spade a spade, but those thoughts will not be otherwise voiced for the duration of my medical education.

The point is that sometimes, it seems like it would be a relief to not have to follow up with every patient on a long-term basis.  While the follow-up gives the physician time to establish a rapport and potentially influence the patient to a greater degree, the medical provider can’t simply “care” a person into good health. 

One aspect of emergency medicine that consistently eats at my nerves is the lack of evidence-based medicine that I have seen practiced.  Certain negative outcomes are simply considered unacceptable.  For example, missing any heart attack.  This seems obvious to most people, but consider this: a lot of women, diabetics, and the elderly don’t have any pain at all.  Some only have shoulder pain or epigastric (upper belly) pain.  This results in a ton of EKGs that really aren’t indicated by evidence.

I had a patient two weeks ago who came in with back pain.  He had a long history of back pain, but his wife was worried about this episode and so she convinced him to come into the hospital.  His Wells score, which predicts likelihood of having a DVT, was a zero out of 9.  Nothing in his history or physical exam suggested a DVT.  However, the liability for missing one is so high that the resident ordered an ultrasound of his legs just to be on the safe side, the entire time griping about how ridiculous it was to constantly be throwing evidence out the window.   

Image

Of course the guy did have a clot in one of his hip veins, or I wouldn’t be telling this story.  Maybe it’s different in other places, especially the more rural EDs without so many resources.  It just makes me sad sometimes that I spend so much time learning complicated algorithms just to throw them out the window because of liability. 

It’s important in these cases to remember, too, that it isn’t about liability, it’s about lives.  In other health systems, including the military, having very small death rates when tests and algorithms don’t pick up every condition in the book is acceptable.  That’s life.  Crap happens.  Everybody suffers, everybody dies.  In the general medical system in this country, however, everyone expects that no mistakes will be made and that every life lost within the medical system should be investigated, assuming that somebody must have screwed something up.  I saw this the most in OB/GYN, but I think that emergency medicine is right up there as well. 

One of my friends from college is an EMT and very into posting things about emergency medicine on Facebook.  I’ve embedded one of the recent posts online because it makes some interesting points.  I’m not sure where it came from, likely either Canada or the UK because nobody in this country says queue.  Take a quick look.

Image

My first thought after seeing this was “what moron would triage a simple cut before any chest pain?”  The person symbolized by the wreath clearly didn’t die because of the people who arrived to the ED before him.  Perhaps the medical community looks at the lady with the cough and thinks, “gosh, what an idiot, why is she going to the ED for a cough?”  But nobody stops to think that maybe she is terrified because her teenage son recently died of influenza (this recently happened in my community).  What if the man with a stomach ache has a ruptured appendix?  Maybe the man with the cut had a relative got cut, infected with gangrene, and had to have a limb amputated. 

Patients outside of the medical profession are often not very good at describing or prioritizing their pain symptoms, so it’s up to the medical teams to differentiate, diagnose, and come up with a treatment plan.  It’s not up to the patients to prioritize themselves, and they are not the ones to blame in the case of an unfortunate outcome—unless, of course, another patient shoots or stabs someone.

One thing the meme does do well is convey health education to the general public.  Maybe people don’t know it’s not necessary to go to the ED for every little thing because that’s the only thing they know.  The picture presents reasonable alternatives and draws attention to the fact that in the vast majority of cases, people can make health care decisions—like calling their primary care doc or picking up some NyQuil at CVS—that do not involve the hospital.  It draws attention toward patient-centered decision making and away from the “I deserve it all, I deserve it now, and you will do it for me” attitude that has become all too prevalent in the United States. 

Something to think about.  My next post will be more light-hearted and contain funny stories :]





Acute Haldol Deficiency

27 01 2013

My first shift in the emergency department took place over the weekend, and I was a little surprised by how the night went—it was not so different from TV.  Minus all of the staff sleeping with each other and being assaulted by the patients.

The biggest surprise was that all of my patients had legitimate concerns (crazy, right?).  The intern told me that this was not normal—in fact, he was complaining that there were so many ‘sick’ people that he hadn’t had the time to dictate proper notes on all of them.  According to him, the ratio of people who don’t need medical attention to those who do is around 3-4 to 1.

The E.D. is the gateway to hospital admission, and after the paramedics and other first-responders, they see people at their worst.  This weekend, so did I.  Two patients in particular spent almost my entire shift (10 hours) in their rooms sleeping off the massive amounts of booze they’d ingested, because social work would not speak with them until their alcohol levels were under 100.

The first, an 18-year-old with very strong borderline personality traits, drank half a handle of vodka beginning that morning, and tried to ‘kill herself.’  She came in stark naked and talking to a giant teddy bear that she’d brought with her.  While suicide attempts are never, ever funny, it’s usually easy to tell the bona fide attempts from the cries for attention.  This young lady had made almost 20 very superficial cuts in her forearm (not over her wrist) with a butter knife before her mother called the ambulance.  The attempt before that involved taking 3 pills (Seroquel, an antipsychotic) and texting a friend immediately afterwards.  While no perceived suicide attempt should ever be brushed off, it’s already become difficult for me to treat the type this girl carried out with the same urgency as the true attempts that come through the door.  The three I’ve seen professionally have had the clear intention of ending a life; one, a man who had gone a mile off the path in a national park and cut his jugular with a razor blade; the others, massive overdoses where the individuals had left notes and not informed anyone of what they had done.

The second was a woman in her early 30s with a habit of guzzling an entire case of beer each day.  She had taken double her usual dose of Trazodone and enough alcohol to bring her blood level into the mid-300s, and she was barely responsive enough to answer questions even with sternal rub (which hurts).  In an unexpected plot twist, her pregnancy test came back positive.  We tried to check whether the baby was still alive, but she wasn’t far enough along to see well on abdominal ultrasound.

Shortly after her arrival, another young-ish woman arrived screaming nonsensically, and it was later deduced from her history and behavior that she was having a manic psychotic break—also referred to by the E.D. staff as an Acute Haldol Deficiency.  She went to the special padded rooms with several security guards to await treatment, and after calming down a bit they allowed her to walk around in the halls.  It didn’t take very long for her to lose it again, and she began to fight the officers and sing at the top of her lungs:

“WE ALL GO MARCHING ONE BY ONE, BY ONE, BY ONE, WE ALL GO MARCHING ONE BY ONE, BY ONE, BY ONE, WE ALL FALL DOWN.”  Over and over and over again.  All of the patients and family members that were able started closing the glass doors to their rooms, then poked their heads around the curtains to see what was going on.  Unfortunately, the 18-year-old who’d cut her forearm did not want to move; as a result, her door stayed open and the other patient, still fighting the security guards, flung herself into the room, her torso splayed across the foot of the bed.

The 18-year-old lost it.  She started screaming and crying, curled up into the fetal position, and refused to speak to anyone for the next 3 hours.  The other woman was still sing-screaming (by now reined in by the security guards) and continued her repetitive song for the next 20 minutes, the sound barely muffled by the padded room.

Those patients, along with several others who were ill, but less exciting, were my intro into emergency medicine.  I will say this much: for the bad rap that emergency docs get from just about every other physician group in the medical community, they handle a lot, and I am enjoying my experience so far.

 





A (Very) Delayed Reflection

25 01 2013

Last night before I went to bed, I reflected a bit on how far I’ve come since this time last year.  Not only have I completed 3rd year and almost all of my required medical school clerkships (only EM to go), but I know what I want to do with my life, have a project for my MPH capstone, and have a solid list of places I would like to apply to residency.

I also have hundreds of patient stories tucked safely in a file folder of my brain, and I can really see now what experienced physicians are talking about when they say that you will carry some of your patients with you for the rest of your life, and those interactions and their outcomes have already begun to shape not only my professional interactions, but they often spill over into my personal ones as well.

If you’ve ever read the book The Things They Carry by Tim O’Brien, or if you knew a soldier in the Gulf, Vietnam, or Korean wars, you’ll know that soldiers could only take the personal items with them that the could bear the weight of on their backs.  As a result, some chose to carry only memories with them on the front lines.  After the past year, though, I would argue that often times the weight of your memories can impose even more strenuous a burden than any physical object could.  Those types of weight, the emotional and psychological ones, can also be the most difficult to drop.  I haven’t experienced any events whose emotional impacts could be considered traumatic; there have been some very low days, and there have been some great days, but over time any extreme emotions have fallen away.

For the most part, though, the really positive events have balanced out the negative ones.  Just as I was drifting off to sleep last night, I was reminded of one of the best experiences I’ve had in medicine, one I haven’t shared here yet.  This is either because the overall negativity of that rotation temporarily overshadowed it, or I hadn’t realized the impact until recently.

This couple came to the hospital late one afternoon when I was working on the labor and delivery floor.  It was about 5pm, and my shift ended at 6, when a woman came into triage in labor.  The resident shooed me into the room to “get the story.”  I don’t remember her name, or her husband’s name, which sounds terrible considering the impact they had on me.  She was transferred from a hospital about 30 miles south, which was odd because nothing about her labor was complicated up to that point.  She was almost completely dilated but refusing to push.

When I first went into the curtained partition, the husband startled and rushed to cover his wife.  They were Muslim, and believed steadfastly that the woman could not be seen by a male health professional at all.  They had asked for a transfer from the other hospital because she had gone into labor and no female physicians were scheduled to be on duty there that evening.  Her husband had driven her to us.

They were a very kind, good-looking Yemeni couple in their mid-20s, and I liked them.  The husband asked me with concern in his eyes whether I could make sure that only women (aside from himself) would be allowed into the delivery room, and I had to take a moment to think about it.  There was 1 female resident and 1 female attending on then, but after shift change at 6, there would be 3 female residents on night call but no female attendings.  This could pose a problem in an emergency, but they knew the risks.  I was just a 3rd year student with no power or influence at all over the physicians, but I needed to advocate for this patient and her husband.

So I found my cajones and spoke up.  The residents looked at me like I had a Venus flytrap growing out of my nose.  The immediate reply was “No, She’ll get whoever is available to deliver her baby.  This is a teaching hospital.”  I asked again, got another non-committal answer, and then changed tactics.

“What if I ask Dr. S if she is willing to stay a bit late to help with this delivery?” I said, and then the 3rd year resident shrugged.  He said there was no harm in asking, so he picked up the phone and made the call.  Not 5 minutes later, another (female) resident had interviewed and examined the woman, determined she was fully dilated, and wheeled her back into a real room.  It took her less than 2 hours to deliver a healthy baby boy, and then I went home.

The next morning when I went in to do my post-partum day 1 note, I smiled at the “Female Staff Only” sign on the door.  The new parents thanked me several times for making sure they had a safe birth experience, and at the time I graciously accepted their thanks but brushed it off in my mind, feeling that I hadn’t actually done anything.  Each time I visited, they asked me to explain and affirm the advice that the doctors, nurses, and lactation specialist had given them.  They knew I was a student, but they seemed to trust my opinion more than some of the trained professionals who were taking care of them.  It was very weird.

Because I wasn’t a health professional, they even asked my opinion of the baby’s name, which they had not even revealed to anyone in the family.  They had a strong, significant Yemeni name picked out, but both were nervous that the name would be too confusing for the baby’s American peers and were considering naming him Ameer instead.  After the difficulty they’d already encountered with keeping their faith and their heritage in a community that isn’t always enthusiastic about accommodating such concerns, I felt for these people.  My suggestion was not to waver from the great name they’d chosen, and if they were worried about social acceptance, use Ameer as his middle name and allow his schoolmates to use that name.  And you know what?  After they had thought it over, that’s exactly what they did, and they were grateful to not have to compromise their beloved name selection for the sake of assimilation.

They took their baby back home the next day, and I briefly missed having them there in the hospital to chat with.  Then the rotation reverted to business as usual, and the tiny family stayed in my mind.  It wasn’t until last week that I fully realized why they had made such an impact.

That was the first time that I had ever stepped up, advocated for a patient, and actually made a difference.  The realization was kind of intense.

So there you have it, almost a year late, but published nevertheless: one of my happiest moments in medicine, delayed only because I was slow in the realization.  The funny thing is, as bad as that rotation was, the memory of this couple makes the entire ob/gyn experience much lighter to carry.





Kiddie Brains

24 01 2013

I was fortunate enough during my neurology rotation to spend some quality time in child neurology, which I found much more enjoyable than adult neuro.  Says the one going into pediatrics, right?  It’s not just working with kids that made it so much more enjoyable, it was a combination of the schedule, the variety, the people, and even the illnesses themselves.

The attending was this fantastic Indian doctor who had gone to medical school in India, residency training in England, then moved his practice to the U.S.  All of the relocation resulted in a fantastic accent which, truth be told, took me a solid 3 days to be able to understand.  Unfortunately, most of his patients either had been there for too short a time, or else were not so good at discerning accents.  On several occasions, I wound up having to ‘translate’ for the patients.

Those of you who live or work with somebody who speaks with a thick accent probably know what I mean; you can understand, but the people on the receiving end often cock their heads to the side in confusion.  I had the added dimension of that person being an attending (read: my superior), so in order to avoid being rude I had to try to balance the translating with making it not look like I was translating.

I still don’t know whether I pulled that one off or not.

Another particularly entertaining characteristic stemmed from the sheer number of articles that he had published in the course of his career.  Each time the doc began to teach a new topic, he would start out speaking quickly, pause, say “Wait, let me pull the article,” turn to the computer, and then Google his name plus the name of the disease he was looking up.  Every time.  I was both impressed and entertained.

Adult neurology sees a lot of progressive neurological illnesses, things like Alzheimer’s, stroke, Parkinson’s, and multiple sclerosis.  For all of these, there are treatments, but no cure.  If a patient had a stroke 2 days ago, all the physician can do is wish them luck and send them to physical therapy.  Meds can help Parkinson’s for a little while, but the effect current of Alzheimer’s treatments are minimal at best.  With kids, it’s different.  Most of them have either seizures or headaches, both of which improve to the point of cure as they grow up.

From what I saw, the adult neurological issues tended to worsen over time, while the pediatric issues tended to improve, even with minimal treatment.

However, there were parents that were reluctant to commit to treatment.  These were generally parents with children who had headaches, which is no big deal because once a tumor was ruled out, a headache won’t kill you.  They can, however, really impact important factors for the kid’s future, like school performance and behavior.

One set of parents I remember particularly well had a 6-year-old little boy, I’ll call him Rusty (not his real name), who came in for dozens of episodes of ‘staring spells’ every day.  The diagnosis of absence, or ‘petit mal,’ seizures was clear from the history his parents gave, but just to be sure the doc ordered an EEG to confirm the diagnosis.  After the EEG was over and it was confirmed that Rusty had epilepsy, he and his parents were brought back to the clinic to discuss treating the seizures.  The conversation was going as expected until the neurologist mentioned drugs.  Then the mom looked at the dad, who looked at the mom, who looked at Rusty playing with a plastic puzzle on the floor.  And she looked at me and said no.

“We don’t want to give him any medications, they just have so many side effects.  As his parents, we don’t want to give him anything that will risk his health in the future,” said the mom.

“His seizures aren’t even the serious kind,” said the dad.

So the neurologist, as any concerned physician would, explained to both of them that yes, medications have risks, but so do long-term, frequent seizures.  There’s a risk of lagging school performance as well as impaired social relationships, but worse, there’s always a risk of permanent brain damage, or that the little seizures could generalize into much more severe grand mal seizures and even lead to death.  That is an extreme example, but it has been known to happen.  As scary as the media and all-natural-guru parents on the internet blogs make the medications out to be, forcing your kid to live with long-term seizure activity is the worse option to me.

It’s not as if non-pharmaceuticals shouldn’t be used for epilepsy.  The ketogenic diet is a very effective treatment for a lot of kiddos with severe seizures that have failed 5 or 6 of medicine’s best drug treatment, sending 1/3 of the kids into permanent remission.  But Rusty had a very common type of childhood seizures that could have been easily treated with a very minimal risk of side effects, and a microscopically small chance of a serious side effect.

I was also trying to figure out, for the duration of the conversation, why on earth the parents would bring their seizing child into the neurology clinic if not for him to receive treatment.

In the end, the parents scheduled a follow-up appointment for the following week so they would have time to ‘do some research,’ and we offered up the names of websites that are full of sound medical information.  I never saw them again, and don’t know what they decided to do.  When the child grows older, though, he will likely ask his parents about their choices only if something goes wrong in the course of treatment.  If it was a side effect of the medication bad enough to put him in the hospital (like Stevens-Johnsons), he will ask, “Why did this happen?”  If he has a grand mal seizure after no intervention, he will ask, “Why did this happen?”

I’m not a parent and can’t even pretend to understand the gravity of making choices every day that impact your kid for the rest of his or her life, but looking at those situations, I know which answer I’d rather give.  You can either tell your kid that the rash was something bad that happened because you were trying to help him get better, or you could tell him he’s sicker now because you didn’t try to make him well before.