Pain Control

So much for a daily blog...inpatient pediatrics on the hem/onc team has come and gone in a blur. And I enjoyed it...in a "I could see doing this for the rest of my life" kind of way. What did I like? I liked the kids...though they weren't always warm and fuzzy (but who could blame them?). One little 2 year old girl I took care of with Burkitt's Lymphoma was so adorable...she would brighten up my morning being super cute and playful (and she liked my hummingbird stethoscope!). I also took care of another 2 year old girl for almost the whole 3 weeks I was there and she never really opened up at all. She was in the hospital for her second autologous peripheral blood stem cell transplant where they give intense chemo and totally wipe out your bone marrow and then give you some stem cells back. That can't be any fun. I think she's understandably warry of doctors. You just want to take away her pain. Then there's the 17 year old who had just been diagnosed with Diffuse Large B-Cell Lymphoma but still seemed like your typical teenage boy (just a little skinny and bald) who'd stay up all night playing video games. For some reason, the kids with recent diagnoses get to me the most because you can so easily imagine them going about their normal lives and then suddenly getting steamrolled with this news. But you adjust. Getting to follow kids over the course of their treatment and beyond and be there to support them through an incredibly rough part of their life seems to be a really rewarding path.

Though you also have to torture them. Cancer's not exactly a picinic but often times the chemo makes them feel much much worse. Mucositis, nausea, crazy infections, spinal taps...honestly. While the cure rates for cancers such as Acute Lymphoblastic Leukemia are now quite impressive and inspiring, there has to be a better way. As much as I thought I was sick of lab work, I like that a big part of a career in hematology/oncology is research oriented. A big part of the patient management also involves pain control. Both the sickle cell kids with vaso occlusive pain crises and many of the oncology patients are candidates for patient controlled analgesia...in other words, lots of morphine or dilaudid at the push of a button. No reason for people to suffer unneccessarily. Probably the most intense thing I witnessed on the rotation occured with a little five year old girl with an unresectable recurrent Wilm's Tumor who was in pain over night. She had just had surgery and her parents had just received the dismal prognosis and the resident on call did everything he could think of to help with her pain, but it wasn't enough. The next morning the mother was livid and came in to rounds screaming at the resident with more hatred in her voice then I think I have ever witnessed in person. Why didn't he call someone to ask for help? How could he make her daughter suffer? Who did he think he was? Unfortunately this was all directed at one of the nicest residents in the world, but he probably should have sought help. And not all of the anger was due to the mismanagement of the pain, there was also the despair of a mother coming to terms with her daughter's impending death.

Sometimes there's only so much you can do. One five year old boy was diagnosed with an untreatable tumor on his brain stem a year ago. It couldn't even be biopsied. Then when it grew to the point where it could be safely biopsied, they discovered it was treatable...but by then it had also compressed his spinal cord to the point where he was paralyzed. Now he's super cushingoid from tons of steroids and he got a decubitus ulcer from being immobile. Then he developed a clot around his PICC line when broke off and caused a pulmonary embolism. Then when he was given heparin he developed an active brain bleed...so he was taken off heparin and now he's just kind of hanging out, waiting for something to happen . We're not really doing anything for him, but we can't really send him home in this condition. How do you deal with that?

Most of the kids are only in for a few days at a time, for scheduled chemo or acute fever and neutropenia. Some kids with Acute Myelogenous Leukemia pretty much just hang out at the hospital while waiting for their white counts to recover (though we discovered just how important it is for them to be nearby when one girl who had been happily running around the halls suddenly developed acute appendicitis). Then there are the kids who get sent home for hospice care...as a parent and a doctor where do you draw the line in pumping kids full of chemo when there's really no hope left? No easy answers...but that keeps it interesting. Unlike endless well-child checks, hem/onc presents seemingly continuous problems that are challenging and thought provoking.

On our second day we were faced with the classic ethical dilemma of a Jehovah's Witness whose 3 year old daughter with sickle cell was admitted for splenic sequestration and required a packed red blood cell transfusion. The parents absolutely did not want it, though there was some discussion that maybe they really did, they just couldn't allow it and go against the church. As we were watching her hemoglobin drop the attending decided that she absolutely had to get the transfusion and we'd just have to circumvent the parent's wishes with a court order or the girl was going to die. It was all very dramatic, but when the parents witnessed the improvement following the transfusion I think they decided not to sue the hospital. I understand respecting religious beliefs...but how could you actually watch your child die? Is thinking your child is possessed by witches and performing elaborate and dangerous exorcisims that much more crazy then denying them a life saving treatment because of a few random passages in the bible?

I'm a little sad the rotation is over...I wish we had another week since this was one of the rotations I wanted to do most. But I've also been stressed out precisely because this is something I'm interested in and want to pursue and therefore I really want to do well in it. And I feel like I did ok, I can present patients, suggest changes in pain control and IV management, maybe even which antibiotics to use, but I was just never the amazing wonderful student I wanted to be. I like working with the parents and the kids and I think I did that well. Our residents were all great (we went out to a Peruvian restaurant together) and the fellow and attendings were nice, but it's nerve racking when their evaluations are such a big part of your grade. And then I feel guilty because I'm surrounded by people with real problems and I'm worrying about grades. Why can't our school just be pass/fail?