After being admitted for an asthma exacerbation, our two and a half year old patient was doing better and ready to go home so we decided to round on her first.

Her room was dark, and our big team filed in.  Attendings, residents, nurses, medical students.  Someone flipped on the light and I squinted, confused, wondering why she wasn’t in her crib.

Her crib had been stripped down, and urine-drenched sheets flung about on the floor.  Her young mom was curled up on a fold-out couch with three blankets which she pulled up over her ears to try and block out the noise.  Our noise.  Her daughter’s doctors.

And over in the corner, exposed and shivering in a rocking chair, was our wet little patient.  Just sitting there, waiting for her mom to wake up and finish taking care of her.  Or, at least just waiting for something to happen next.  She blinked and stared straight ahead.

Her nurse, appalled, went to get more sheets and a clean gown.  The medical students were embarrassed.  My Attending was upset and began to try and wake up the mother, even as she shooed him away.

I picked up a blanket and wrapped it around the little girl.  She scurried up on to my chest and locked her wiry arms around my neck.

And for the longest time, we all just stood there, enveloped in her neglect.  And the realization that this was something we could not fix.

Now Playing:  Badly Drawn Boy - Is There Nothing We Could Do?

“It’s all wrong. By rights we shouldn’t even be here. But we are. It’s like in the great stories… The ones that really mattered. Full of darkness and danger, they were. And sometimes you didn’t want to know the end. Because how could the end be happy? How could the world go back to the way it was when so much bad had happened? But in the end, it’s only a passing thing, this shadow. Even darkness must pass. A new day will come. And when the sun shines it will shine out the clearer. Those were the stories that stayed with you. That meant something, even if you were too small to understand why. But I think…I do understand. I know now. Folk in those stories had lots of chances of turning back, only they didn’t. They kept going. Because they were holding on to something.”

Sam to Mr. Frodo

For all intents and purposes the majority of what we treat in the “Emergency” Department is really not so much of an emergency at all.  There are the occasional cases of severe asthma, and bones which need to be set back into place, but on any given night you will find more bed bugs and runny noses than all other “emergencies” combined.

And so it was with my 4:30 am infected toe.  Really.  While not an emergency by any means, the infection did need to be drained.

I gathered up the supplies to numb the toe and then the tote needed to lance, clean and dress it.  I also grabbed a “helper” to hold the kid down and a Child Life Specialist to distract him.  Blow bubbles, guided imagery, etc.  A billion times more useful than the Holder, actually.

I also grabbed my attending doctor because the last time I did a digital block, I accidentally stabbed myself with lidocaine before the procedure began and had a numb hand for forty-five minutes.

As the Child Life Specialist got out an enormous pair of sunglasses and a beret, the Holder flopped herself on top of the child’s good leg while the mom held down the injured one.

I began to inject a smidge of the numbing medicine into the toe and the kid went ballistic.  Child Life frantically blew bubbles which kept popping on my nose and in my eyes.  In retrospect, the needle I was using was entirely too small.  Though it was less painful, it was still a stick nonetheless, and the lidocaine took FOREVER to instill  Next time, kids, I’m using the big needle, so watch out!

I had planned on using about 4 cc’s of numbing medication but after only a half a cc, my attending told me to stop and just “make the cut” (i.e. get the infection out).

I did, and I am pretty sure the kid felt it, because the histrionic scream turned into a REAL scream as pus flooded the basin.

Then the mom asked if I would take off the toenail.  I told her no because we don’t usually do that, AND it will fall off on it’s own without any complications.

My attending had other ideas, however, and told me to take off the toenail.

“I’m not very comfortable with that,” I said.

“Well, get comfortable because this is General Pediatrics.”

“I don’t think my digital block was very good.  He can still feel this..”

:::poke::: SCREAM!  (from Child Life this time as well, in addition to the kid)

“It’s almost off, Danielle.  Just 1-2-3 rip.”

At this point, the mom was gagging, the Holder was getting kicked in the face and Child Life was singing some sort of forlorn campfire song.

Now, I could have just ripped it off.  I could have. It was probably the right thing to do.

But you know what?  No, I couldn’t.  Because I was totally going to THROW UP IN MY MOUTH.  It was so disgusting.  I am sorry, but it was!  There was no way that I could rip off the toenail of an un-anesthetized person.  Like some doctor from a horror movie.

So I quietly said, “I can’t do it.”

“What?!” everyone said at once.

“No.  I won’t do it.  I am sorry, I am not going to take off the toenail.”

I stood up, peeled off my gloves and prepared to vomit in the choo-choo train trashcan, however I was temporarily blinded by the steam shooting out of my attending’s ears.

“Give me a pair of gloves NOW.”  :::steam, steam:::

:::::::::RIPPPPPPP:::::::::

Off came the toenail.

Not that I will ever know for sure, since my eyes were shut.

Now Playing:  Ohio (Come Back To Texas) -- Bowling for Soup

There is a family in my continuity clinic who has a little girl with severe disabilities secondary to a brain tumor she had removed right before she entered kindergarten.

Her mom and I get along very well, and I can tell she trusts me.  She was one of the first people to really trust me, and I hold on to this.  I would move mountains for them, if I could.  But mostly I just write prescriptions.

When I saw her in clinic this week, things were going well and I asked about the girl starting school again, now that she is stable and healthy.

Her mom sat back and looked around me at a feisty red-haired little girl that I never knew.

“You know, two years ago I took her to have her eyes checked before kindergarten.  We were going to get a lunchbox after the visit.  The eye doctor saw something in the back of her eyes and then we had a CAT scan.  We went to surgery the next day and then she went into a coma and I never got to talk to her again.”

I found it strange, the way she phrased it, that she never talked to her again, because she talks to her every day.  I supposed she meant that the little girl doesn’t talk back.

Or maybe she means simply what she said.  She never talked to her daughter again, and now she has a new little girl.  Not someone she asked for or wanted, but someone she has.

“We never did get a lunch box.  Maybe we can do that this year.”

A 5-year-old boy came in with urinary complaints.  He was drinking an orange soda when I saw him, and had a bright orange soda mustache above his upper lip.

“Do you think you could pee in a cup for me?” I asked, hoping to test it for infection.

He belched and wiped his lip.

“I guess so.  But it’s gonna have to be a pretty big one!”

It’s 3:00am and I am in the ER, stitching up the macerated back of a 6-year-old boy who was thrown into the dashboard of the car his intoxicated mother drove into a ditch.

“Will it hurt?” he asks me every time I get another set of suture out of the box.

“No,” the nurse coos into his ear.  “You had the numbing medicine, remember?  No more ouchies.”

My hands shake because I am nervous I won’t do a good job.   I know I can close the wounds, but I want him to look perfect again.  There are large hunks of flesh missing, however, so I settle for doing the best that I can.

He tries to drift off to sleep, and I keep working.  My cold tools touch his warm flank, and he startles.

“I landed on top of my mommy.  I was crying.”

“I know, buddy.  That was so scary.  You are so brave.”

“Is she OK?  I landed on top of Mommy.”

“She is going to be OK.  She’s getting stitched up too, just like you!”

“Yeah, she probably didn’t cry like me, though.”

Maybe she didn’t, but we will.

As part of my elective time, I have been spending the mornings working with Pediatric Anesthesiologists, improving my intubation and IV skills.  Saying I work with an Anesthesiologist is actually a bit of an exaggeration.  Mostly I work with nurse anesthetists.  The doctor peeks his or her head in every now and then, to bill I guess.  Some days I think I should have been an anesthesiologist.  Or a barista, but I digress.

I have to have the attending doctor, however, sign off on my skills.  At first I was worried about figuring out which  green-scrubbed, masked-up person was the attending and which one was the CRNA.  But that became much less difficult as I spent time in the OR.  Some of the CRNAs were fantastic with patients and taught me amazing tricks of the trade.  Many more, however, were crude in the OR, made comments I found to be inappropriate and over all seemed highly unprofessional.  Sure, they followed the script and practiced safe medicine, but healing and caring for someone is so much more than that.  I’ve been mostly underwhelmed.

My favorite interaction:

“Well, “doctors,”  if no one is going to make a decision, I am just going to have to take over!” as she proceeded to shove a biopsy tool down the throat of a patient before the surgeon had time to object.  He, by the way, was discussing the best approach with two senior surgeons standing next to him.  Trying to do the right thing.

And I am just going to say it.  Because I wasn’t sure I believed it until now.  But I do.

There is something to be said for a hierarchy.  Something to be said for respect and professionalism in the work place. And though we have all heard stories of surgeons being snippy and nasty, I am telling you that it goes both ways and it really, really is a sad thing to watch. Whether it be on a construction site, at a law firm or in the operating room where your 4-year-old child is lying unconscious.

Respect is dying.

Now playing:  Airplanes (clean) -- B.O.B

When my little cousins, ages 6 and 4, met my 6-week-old niece, Julia, for the first time, they “oooh” and “aahed” appropriately.  Maddy said, “I like Julia.  She’s pretty.”

Later, they crowded around her, caressing her soft baby hair.  The older of the two, Emily, was singing quietly.

A lullaby for the little lamb?

Nope.

Single Ladies.  (“all the single ladies, all the single ladies..oh oh oh. Oh Oh Ooooh.”)

Recently, it seems, it’s been my job to undo things that people have done to themselves.  This is the very thing that drove me away from adult medicine.  The pressured-chest, tight-throat feeling that this is mostly your fault.  Something that is rare in Pediatrics.  You don’t choose to be born with a broken heart or to be born into a family who hurts you.

But you do choose to swallow two bottles of Extra Strength Tylenol.  You choose to drive drunk and not wear your seatbelt.

And maybe you don’t choose to starve yourself into electrolyte imbalance and osteoporosis, but at 2:00 in the afternoon when I am arguing with you over whether or not you have to eat two carrot pieces, it sure feels like this was your choice and now we are all being punished for it.

I remind myself of all I have learned about eating disorders.  And of people I love who hurt themselves.  But looking at you, beautiful and selfish, I forget all of that. Everything becomes hazy in the anger of wanting to fix you.  Stop. Acting. Like. This.  There’s a whole wide world out there, honey, and you too could be a functional person!  I mentally shake you awake, and your bleach blond hair flops around, indifferent.

And how you will ever even start to believe that you are worth it, I have no idea.

Now playing: Hazy  by Rosi Golan

Today, for the first time, I felt like I gave my intern a good piece of advice.

It seems that only happens through personal pain and struggle.  At least for me.  Learn from my mistakes, I say.

Always, always do the right thing, at any cost.  Then, talk less about having done it.