8 posts tagged “pediatrics”
MRSA seems to be everywhere lately. At least I've been reading more about it on the web and encountering patients with MRSA infections in the ward.
Two weeks ago a 2-year old boy was admitted with a chief complaint of swelling of his right thigh associated with fever and decrease in urine output. The swelling had started a few days prior to admission and on consult had spread from his thigh to involve his gluteal area. The boy was put on intravenous antibiotics -- Ampicillin and Gentamicin, then Oxacillin and Metronidazole, then Piperacillin-Tazobactam, etc. all to no avail. Whatever was causing the infection was not responding to his medications and now the causative agent was circulating in his blood. He developed pneumonia and an acute abdomen among others and had to undergo exploratory laparotomy. After the surgery, culture of secretions revealed MRSA. IV Vancomycin was started and the boy's condition improved over the next few days.
A few days ago a co-interns case management discussion was again about MRSA.
MRSA or Methicillin-Resistant Staphylococcus aureus is a bacteria that causes a variety of infections from mild skin infections such as boils or cellulitis to more severe illness such as pneumonia and sepsis. Initially confined in the hospital setting where it developed its resistance to antibiotics, in the past few years a community acquired strain has emerged.
I've always found MRSA intriguing ever since I first heard of it in med school. Although not as commonly found as other infections according to Boston Globe fatalities attributed to Staph may exceed AIDS deaths in the US. In New York, a recent Staph outbreak affected nine athletes and their coach although only one had to be hospitalized.
Elsewhere, I came across PhD graduate Nick Yee's documentation of his experience when he developed a MRSA abscess.
More about MRSA from Mike the Mad Biologist.
There's just something about working with children that brings out the kid in you however deeply hidden it may first seem. Right now the little kid in me is enjoying this video very much:
And this one, too!
Picture this:
A little after eight in the morning at the AVR. Admission Conference. There are two tables in front facing the audience and behind them are the pediatricians-in-training from duty - 2 residents and 3 pre-residents wearing their short white coats over scrubs, the pre-res in their shiny white Nike's, the residents in rubber slip-ons. Directly in front of them is an elderly consultant all made-up, dressed in a lavender suit and blue flats, three evaluation forms for the pre-residents in her hands . To the right are the two chief residents, both petite, both with long black shiny hair, both wearing short flippy skirts and pointed heels - definitely not suited for rounding but highly appropriate for their administrative and training roles. Behind them are the rest of the residents, or at least most of them. The post-graduate interns are seated at the left: they are the ones who arrive early in their white skirts and blazers, their thick and heavy Nelson's Textbook of Pediatrics opened in front of them. Behind them are the other pre-residents, hopeful for the day to come. All around the back are the junior interns, still early but already bored.
On most days this is where I derive most of my learning - sitting up front, attentive, all eyes and all ears, heart pounding in my chest every time the attending searches for someone to call. Heart pounding . . . heart pounding . . . fast breathing.
And then picture this: me waking up early in the morning, excited, looking forward to all these.
In 2004 the Department of Health launched a follow-up campaign (Ligtas Tigdas) for catch-up mass immunization in which 17.2 million children from 9 months to below 8 years of age were given a dose of anti-measles vaccines nationwide. From 2004 to before November 2006 only 5 laboratory confirmed cases of measles were reported leading one to believe that the campaign was a success. However, 2 years after the campaign was launched several measles outbreaks have been reported in certain areas of the Philippines. In response to the outbreaks the DOH has launched a second follow-up mass measles immunization.
Knockout Tigdas
Early in the morning Secretary of Health Franciscio Duque dropped by the Philippine Children's Medical Center to officially launch Knockout Tigdas. As part of the campaign to eradicate measles in the Philippines by 2008 a "door-to-door" mass immunization will be held from October 15 to November 15, 2007. Aside from giving free measles vaccination for children 9 months to 4 years old, vitamin A and deworming are also offered. If I remember correctly, they are targeting over 2 million children prioritizing those in hard to reach areas, urban and congested communities.
Reach Out and Read (ROR) is a non-profit organization that promotes early literacy by giving new books to children and advice to parents about the importance of reading aloud in pediatric exam rooms across the nation
Parents trust and respect the guidance that they receive from pediatricians. When doctors and nurses discuss the importance of reading in an exam-room setting, parents realize the significance of the message.
Currently, there are 4 centers/hospitals in the country involved in ROR. They are very much welcoming volunteers who will read to the children and donations in the form of books. The pediatricians and health care workers role is to encourage parents to read regularly to their children and give them the tools (the books) to do so.
I would love to see the eradication of measles in the Philippines come into fruition. Personally, I cannot deny that Reach Out and Read is closer to my heart. As it is, it has already been awarded by UNESCO the 2007 Confucius Prize for Literacy. I would really love to see more children reading. Actually, I would really, really love to see both these campaigns turn out a success.
Things are going well in my current rotation. There are periods of dullness when I am left with absolutely nothing to do except stay in the medical library and read my Nelson. During the times when I actually get to see patients for my Pedia subspecialty rotation I am more than impressed regarding case management and the ongoing doctor-patient relationship. This leads me to discuss the "notebook system" that the subspecialty clinics employ.
I have rotated in the Hematology/Oncology and Pulmonology Sections already and both of them employ the "notebook system" for inpatients as well as outpatients.
The "notebook" for most of the patients is a tiny colorful lined notebook selling for ten pesos in the hospital tiangge (flea market). While the appearance of the notebook may be deceiving in its frivolity, the content is certainly an important part of health management. Patients bring their notebooks every time they visit the hospital. The notebook contains notes from the fellows, current medications, and future plans for treatment. With almost everything that has gone through the doctors mind written in the notebook and explained to the patients/parents a high level of patient compliance is expected. Some of the patients have a second notebook in which the parents keep a diary of signs and symptoms. A glance at the pages would reveal something like the following:
9/24/07 - okay siya (he's okay)
9/25/07 - may sinat sya (he had low-grade fever)
9/26/07 - okay na siya. wala ng sinat (he's already okay. no more fever)
9/27/07 - okay naman
9/28/07 - okay naman
9/29/07 - inubo ng konti (he had cough)
Pages and pages of text go on like this allowing the doctors to get a clearer picture of the patients' health when they are at home. For others, chronicling the health of their children is even easier. A data table is penned into the notebooks with columns of symptoms and all the parent has to do is to check the appropriate symptom for the day.
The "notebook system" is so simple yet seemingly so effective in helping pediatricians offer the best possible health care they can offer. At the same time the parents are given a more active role in coaxing their children from sickness into health; they become an integral part of health care.
Somehow, for me, this inspires confidence.
Some form of the ideal can be gleaned in today's medical system sometimes :)
I seem to be taking a longer time of getting the toxicity of my previous rotation out of my system.
I'm still in Pediatrics but currently rotating in Pediatric subspecialties in a different hospital and very much enjoying the learning experience. I find myself loving admission conferences where the residents (or pre-residents) from duty present the admissions during their tour of duty. So far I have not embarrassed myself and managed to answer the occasional question the attending throw at the interns. In 5 days I have learned more than I could possibly learn from reading textbooks in a month.
While I probably wouldn't go into Pediatrics I have developed a greater appreciation of the effect proper management of children's disease have on the patient and the parents as well. Seeing your patient wave goodbye to you on their way home after a lengthy stay in the wards is definitely a boost to your tired body and frequently bruised ego.
Here's to looking forward to more learning in the following weeks.
I remember dissing roommates in college, not out loud nor to their face, but just generally frowning upon what they called as a dorm-life boon of ramen or instant noodles. Of course there’s always some place cheap to eat on campus but when it’s the middle of the night and you’re in your jammies the last thing on your mind is to go out and get some food from a lutong bahay or food kiosk at the corner. While I highly question the nutritional value of instant noodles, the nutritional value is not what I’m worked up about. Although most of the time I think a nice sandwich would be better, I do know that a sandwich with overly sweet jam would come to the same thing. My point is, in my current state in my Pediatric rotation I’m eating my words and find myself really glad to come home post-call to an apartment with instant noodles in the cupboard.
My last 24-hour duty in the Pedia
ER was horrible. I was feeling a bit
off early in the morning already since my allergic rhinitis has been acting up for
days. Plus, I had a feeling an asthma
attack was imminent. So I prepared for
it. I took an antihistamine, a
decongestant and a couple of actuations from my Salbutamol inhaler and things
were fine with my health and the general flow of patients in the ER in the
morning and the better part of the afternoon until all hell broke loose in the
evening.
I had a
day old baby who arrived with no pulse, no spontaneous breathing and completely
devoid of color. I had a 15-day old
septic-looking baby brought in by her 17-year old mother. I had a newborn with gastroschisis delivered
at home, long segments of his intestines extruded from an abdominal defect. I had 4 or 5 patients who came in due to
febrile convulsions, two of which convulsed one after the other in the ER. I had a couple of patients who came in from
another hospital after being treated and given home medications go through the
whole Pedia ER work-up again because they weren’t convinced that they were
managed appropriately by the previous hospital.
The irony of it was, we treated the patients the same way and during the
course of our observation the parents ended up deciding to take the patients
home against medical advice anyway.
Half of the patients I saw came in
due to difficulty of breathing, all of whom we subsequently diagnosed with
pneumonia except for a couple who had bronchial asthma. These children had been having fever, cough
and colds for days. Half of them had not
seen a physician prior to consulting at the ER.
The Pedia resident on duty, in her good humor and genuine concern, kept
on berating each parent for waiting until the kids were already in respiratory
distress before seeing a physician when they could have easily brought them to
a local health center when they were still having simple colds or cough.
Oh, don’t get me wrong. It was a great night on call at the ER. I just wish I wasn’t so drained the morning
after that it is all I can do to take the short jeepney ride home, take a
shower and get into bed without eating breakfast (or lunch!) I woke up 4 hours later to find an empty
fridge and only a packet of instant noodles to tide me through the day. Yes, I suppose in this case instant noodles are indeed a boon.
I'm already halfway through my general pediatrics rotation and all I can say is I hate being post-call.
The little people are a force to be reckoned. They fall into one of two categories - either they're adorable or downright annoying. Most of the time they fall into the second category. I can't really blame them. On top of feeling horrible about being sick the diagnostic/therapeutic procedures (serial blood extractions, gastric lavage, lumbar puncture, IV line insertions, etc.) we put them through can only be construed by these kids as torture. By the end of the day I find myself so tired that it is all I can do to give a sympathetic face to the sleep-deprived parents who worry over every degree of temperature rise or episode of bowel movement.
More to come about my Pedia rotation in the next few days.
