“You WILL get sick on your pediatrics rotation.”
This was said to us by our clinical coordinator during Transition Week, a one week crash-course on the expectations/requirements of clinical year.
“I know you think you won’t get sick.” (I did think that). “But trust me, no matter how careful you are, you will.”
At the time of my writing this, I have actually completed 6 out of 9 rotations for clinical year. While my original plan was to write one of these posts after each rotation, I am actually kind of glad I waited. I feel I have a much better perspective now because I have other clinical experiences for comparison. My plan for each rotation post is this: a brief synopsis of my experiences followed by advice/lessons-learned. As always, my ultimate goal is to make my blog posts useful for future students.
Pediatrics was actually a great rotation to have as my first. The patients tended to be low-acuity and the diagnoses simple. A major challenge of this first rotation was (again) just figuring out expectations. It was nerve-wracking to deliver my first patient-presentation to a preceptor and to write my first real SOAP note. However, knowing it was my first clinical rotation, I felt my preceptors were understanding and helpful.
Yes, I got sick… And I was incredibly careful not to. I doused myself in hand-sanitizer every chance I got (and even considered bathing in it at times). Then one day I was looking down some kid’s throat with a tongue depressor. Sure enough, he coughed. I felt little specks of saliva go all over my face and lips, and that was all she wrote. So heed the warning above, you WILL get sick.
My rotation was split in two. One half was spent seeing outpatients in a small pediatric clinic about an hour away from the hospital. The second half was spent in the hospital seeing inpatients. I appreciated this divide since it allowed me to see a greater range of illnesses, including a few rare ones such as incomplete Kawasaki’s Disease and something called Sweet Syndrome (which felt a little ironic, being in Hershey, PA).
On the whole, seeing pediatric patients is fun. Even when they are crying and screaming their heads off, kids are still at least cute. Having worked for 2 years in the emergency department, I have seen adults pitch similar fits and it is much less entertaining. You will see a lot of sick patients on this rotation, considering kids are essentially Petri-dishes for disease. But as I said, most of the diagnoses are fairly simple. I would say that 75% of the sick patients had some viral syndrome taking place that required little more than supportive therapy. You know, sprite, soup, nasty tasting cough syrups. That sort of thing.
The most surprising thing about outpatient Peds was the number of children who were habitual “school-skippers”. They reminded me of our patients in the emergency department who were known drug-seekers in that they were equally as manipulative and transparent. Some of them presented nearly every-other day with a different story. It shocked me that their parents/guardians would enable this behavior. In fact, in one instance the school called the pediatrician’s office to report that a particular child had missed over 100 days of school that year. (Yeah, I didn’t believe that number either when I heard it).
Inpatient Peds was a little more challenging. For one thing, there is a great deal more formality in the hospital. Preceptors will expect in-depth presentations that are detailed and structured. And considering how complicated some of the patients were, this was a challenging task on my first rotation. However, I was happy to get exposure to it early and felt it was good preparation for future rotations.
My favorite part of inpatient was working in the newborn nursery. Never thought I would hear myself saying this (not a dad yet), but babies are kind of fun. And adorable. I was only in the nursery for one day, but felt fairly confident in my ability to do a newborn exam before I left.
Here is my best advice going into this rotation:
- Listen first; do the hard stuff last. Probably one of the biggest differences between seeing pediatric patients and seeing adults is the order in which you do your physical exam. If a child comes in with with a sore throat and you go head-to-toe with your exam, you are going to stick a tongue depressor in the kid’s mouth and have him crying the rest of your exam. No chance you will be able to hear his heart sounds if you do this. Kids cry. A lot. Sometimes they even cry at the stethoscope, so if there is something you are particularly concerned about (such as bowel sounds) then listen to this first and then move on. Get your listening in while you still can and save the stuff that will make him/her cry until the very end.
- Make everything a game. This goes with the above. Kids are little ticking time-bombs; even the best of them may cry at some point. In addition to having short-fuses, they also have tiny attention-spans. The more you can make the experience of going to the doctor fun, the better you will do. If they have a teddy-bear, listen to the teddy-bear with a stethoscope before you try to listen to them. This normalizes the experience for the child and reduces anxiety. Make them laugh and distract them. Blow a glove into a balloon and hand it to them just before you test their reflexes. Let them grab your stethoscope while you palpate their abdomen. Make funny noises. Tell them how many boogers they have while you look up their nose. Whatever you have to do to get them laughing, it will save you time and energy in the long run.
- Study rashes & asthma before starting this rotation. Rashes are probably the most challenging thing you will encounter this rotation. Even most seasoned practitioners will tell you that they are still perplexed by rashes. The frustrating part is that most rashes don’t have the “classic” features you learn in school. However, occasionally they do. I can’t tell you how excited I was when I walked into the room and saw a little girl with the classic “slapped cheek” appearance of Fifth Disease. You will also see a lot of asthma. Knowing the drugs and treatment algorithm for asthma ahead of time is sure to impress your preceptors.
- Do as many well child exams as possible. This is also a major challenge, considering each age has different milestones, different vaccinations, and different anticipatory guidance associated with it. There is a lot to know, and in my opinion, the only way to learn it all is to do a bunch of these exams. No amount of memorizing charts/graphs in the book will equal the knowledge you gain from simply stumbling your way through these exams repeatedly. I know they are a pain in the you-know-what, but practice really counts here.
- Dodge, dip, duck, dive and dodge. You might recognize these as the 5-D’s of Dodgeball, but they also apply to pediatrics. Always be prepared for kids to cough/sneeze/pee in your general direction. Whenever you are looking down a child’s throat, be ready to move if need-be. While you are listening to their heart/lungs, stay out of the line-of-fire. And when you go to remove a diaper, do it slowly and cautiously. You are going to get sick (there is really no avoiding it). But mastering the 5-D’s might at least keep you from being the victim of bodily fluids.