Friday, December 24, 2010

How not to pee while at the movie theatre...

Being in medical school, I have friends and acquaintences asking me for medical advice all the time. This was particularly disconcerting when I was a first year student and knew little to nothing about medicine. As a third year student, I feel much more comfortable answering these questions because I have learned so much over the previous two years and I have a much better idea of what I don't know, which means I have a better idea about when I should recommend that the friend sees their physician. Most of the questions I get asked start with "I have this rash..." or "I've been feeling under the weather..." but every once in a while I get a more interesting question.

A friend of mine was watching a movie and had to urinate causing him to miss an important scene. Never wanting to go through this again, he wanted help in developing a strategy to avoid a similarly horrendous experience in the future. His one caveat was that he didn't want to give up his 2L pop while at the theatre (yes, drinking 2L of pop at a go is unhealthy, he doesn't care, move on...). One idea was self cathetrization, but he didn't really like the idea of inserting a tube into his urethra (there is also a significantly increased risk of urinary tract infections, so don't do this...).

Alternatively, he could just make sure he ate salted popcorn while at the theatre. How does salted popcorn help? Well, he had to urinate during the movie because he was consuming 2L of fluid and his kidneys were flushing this extra fluid from his body. However, if he ate salted popcorn, this would increase the concentration of sodium in his blood. To bring the concentration of sodium back down to normal levels, his kidneys would initially have to retain fluid...thereby reducing the amount of urine they produce. Over the next few days his kidneys would excrete the excess sodium and the fluid that was retained with it to bring his body back to normal fluid volume and sodium concentration. However, in the short term, producing less urine while watching the movie means that he would not have to pee until the movie is over.

Of course, there are a lot of reasons why consuming excess salt is a bad idea, but this friend is a healthy guy, so his body can take a short term excess sodium load. So this idea will work well for him.

Thursday, December 23, 2010

Kid with a fever....remember Kawasaki disease!

If a kid has a fever, 99% of the time it is due to a cold/flu/infection. 90% of the time, the correct course of treatment is rest and fluids. If the infection is a particularly nasty bacterial infection, then antibiotics are in order. Honestly, antibiotics are rarely necessary and we definitely over prescribe them; however, this is not a post on the evils and consequences of over prescribing antibiotics.

This is a post about one of the multitude of causes that is responsible for the 1% of pediatric fevers that are not due to an infection. When I was doing my pediatric rotation, I saw a boy who had a fever for 7 days. His pediatrician assumed that the boy had an infection and sent him home without doing a thorough physical exam. Over 99% of the time, this would have been okay. Unfortunately, this was a rare occassion where the pediatrician really needed to perform a thorough examination on this child.

If the pediatrician had taken a more thorough look at this boy, he would have noticed a strawberry tongue, rash, swollen lymph nodes, and peeling of the skin around his hands and feet. The boy had Kawasaki disease. Kawasaki is an autoimmune vasculitis which results in the patient's immune system attacking medium sized arterial vessels. If this boy had been diagnosed when he saw his pediatrician, he would have been admitted to hospital, started on IVIG, and I would not have a story to write about. Unfortunately, he was not diagnosed until months later, when he developed a consequence of Kawasaki disease...coronary artery aneurysms. Now this boy is at increased risk of cardiac a child.

The lesson here isn't to always assume that your child has Kawasaki disease if they have a fever. The lesson is to make sure that your pediatrician, or any doctor you see for that matter, shows an effort to be thorough. If you have a doctor that is only willing to spend 2 minutes with you, it might be time to find another doctor. Now, it is unrealistic for you to assume your family doctor will spend 30 minutes with you if you have a cold...but if you really feel sick and your doctor doesn't seem to address your concerns, are you really receiving the health care that you want?

Monday, December 20, 2010

Pediatrics as a Med Student

My first third year rotation was in pediatrics at my province's major pediatric hospital. Pediatrics is a great first rotation because the attendings, residents, and nurses are used to dealing with children, so they are patient. At the start of third year, patient co-workers are probably the most essential part of our learning because we have very little practical medical experience.

Learning how to function in a hospital as a medical student isn't easy. We are learning how to manage our patients both medically and personally; understanding the medicine isn't useful if we can't build enough rapport to elicit a history. We also have to bridge the gap between the attending physician/residents and the rest of the hospital staff.

Throughout the first two years of med school, we are constantly warned about third year because being at the bottom of the medical team totem pole is a terrible place to be. Why? Because crap really does slide downhill... If the medical team is upset with the nursing team, they yell at us. If the nursing team is upset with the medical team, they yell at us too. At the same time, we are never supposed to demonstrate any outward signs of distcontent at the anyone. The mentality is: "you know how many people tried to get into medical school but didn't, you're lucky to be where you you should thank me for telling you that you're incompetent because you didn't do the thing I forgot to tell you to do".

However, my experience in pediatrics was fantastic because all of the staff were interested in teaching us and most realized that we were in the infant stages of our training.

Another challenge in pediatrics is dealing with patients. We have all worked with patients in first and second year, but now we actually have to manage acutely sick patients for the duration of their hospital stay. Particularly difficult in pediatrics because kids are not rational, dislike waiting, and often fail to communicate important issues. We are told to rely on parents to liaise with their kids...this is often a good idea, but sometimes it's actually a terrible idea. Having a child who is sick enough to come to hospital is a stressful situation and some people deal with stress better than others. Some parents are calm enough to provide excellent histories that thoroughly describe their child's problems. Other parents are too overwhelmed by their child's illness to be able to remember anything relevant about their child's health. Histories are usually more important than any physical exam or laboratory investigation we can undertake. Thus, if we don't get a good history, we are much slower at starting the correct management for our patients. Delays in management mean extended hospital if you don't want your kid to be in hospital any longer than they need to be, make sure you can provide a good history!

So my take on pediatrics as a med student:

1. The staff are usually very friendly and easy to work with.
2. Patients are usually a lot of fun to interact with.
3. Kids rarely want to stay in the hospital any longer than they absolutely need to.
4. Kids usually get better.
5. Kids are hospitalized for reasons that are not there fault (i.e. Not too many kids come into hospital with a COPD exacerbation from smoking).

1. Patients with only one issue to manage...kinda boring.
2. Often can't rationalize with a kid.
3. The bread and butter pediatric patient is either ADHD or failure to thrive.
4. Pediatrics requires very very detailed paper work.
5. Limited job opportunities if you want to sub specialize.

I had a lot of fun in pediatrics, but it is definitely not the specialty for me. In the end, I think I would get bored in the long run.