Week 3: Chief's case

Every morning in the pediatrics department there is a meeting called Morning Report, during which residents present all the cases on the pediatrics floor, and then at the end, someone gives an informative presentation on a topic of his/her choosing. Today, the presentation was a chief's case -- an interesting case that the chief resident presents, followed by a discussion in which the interns and other physicians in the room figure out the diagnosis.

This was the most interesting meeting I've sat in on yet. It gave me a glimpse into the realm of medicine that involves solving puzzles. To a certain degree, every morning on rounds is a puzzle in the sense that keeping a patient stable in the PICU requires a delicate balance of various meds. But most of the time (at least as far as I can tell), by the point the patient is under the care of the cardiologists, the diagnosis has been made.

What I saw today involved figuring out why a baby arrived at the emergency room with a fever, cough, and reddish purple coloring. After that description, the chief turned it over to the interns and said, "OK, so what do you want to know?" And everyone worked together to get to the right diagnosis -- there was brainstorming and discussion and questioning of why the interns wanted to know certain things (e.g., why do you care about sodium levels?). The level of challenging seemed just right -- they had to defend their reasoning, but nothing was ever combative. Overall, it seemed like a supportive learning environment, and one that reminded me a lot of discussions at Bennington.

Eventually, they got to the correct diagnosis of nephrogenic DI (diabetes insipidus), which occurs when the body can't concentrate urine because of insensitivity to ADH (anti-diuretic hormone). Treatment includes medicines (e.g., hydrochlorothiazide) that are actually diuretics, but can also reduce urine output in people with NDI. I don't understand the mechanism yet, despite my Wiki attempts. I'm still unclear how reducing the permeability of the distal convoluted tubule to NaCl (thereby causing less water to osmose from the tubule into the interstitium, resulting in more water lost in urine) would treat the condition. But hey, I know some people who would know, so I'll find out why.

The more I'm here, the more I realize that, when dealing with sick babies as a medical student, I know one of my biggest challenges will be fighting this tendency: