Right Time Right Place
July 11, 2020
There are times when you know you have made the right decision and that you are in the right place. I remember being six months into categorical pediatric residency and working an evening shift in the Pediatric ED at Mans Greatest Hospital (MGH). It was a normal shift. I knew what to do. Who to consult. What orders to write. I was walking down the narrow hallway that separates the two bays of exam rooms when a toddler peaked her head out and saw another toddler. This toddler said in her high-pitched very friendly voice, “Hey baby.” I think she was looking for a playmate. I stopped what I was doing. I paused and I thought “They ARE both babies and that is so incredibly cute.” I was in the right place.
In the same ED but in the orthopedic procedure room, I remember when there was a four-year-old who had a complicated fracture that needed reduction and IV sedation. Eventhough we were a tertiary care center, the pediatric residents placed the IVs. It was great program to learn procedures. By then because it was the tail-end of gastro season, we were very good at IVs. I had my IV setup all ready including multiple tegederms, the clear adhesive you use to secure the line. Pediatricians usually place small caliber IVs like 24-gauge butterfly needles. I think I went big and was going for a 22-gauge in a dorsal hand vein. This child’s hand was so hard to keep in place. I slipped the 22-gauge in like butter. The line flushed fine. But the child was sweating profusely. Tegederm after tegederm kept sliding off his sweaty hand. I needed to dry his hand with a sterile gauze but the child would not stop squirming even with the parents holding him down. Young 25-year-old-pre-mommy-almost-junior-resident-me turned to that kid. I whispered to him in a low and fierce and purposefully evil-sounding voice, “You better stay still because if I don’t get this tape on, I’m going to have to hold you down and do it again.” I stared at him. He went still. I mopped the sweat off with a gauze with my still flushing IV, and secured that 22G butterfly with the tegederm, tape, double arm boards and so much gauze that that IV wasn’t going anywhere. I remember a medical school classmate was the orthopedic resident in the room and he smirked. Yes pediatric residents can be badass too, I thought.
That is the dichotomy of being pediatricians. We are the ones who live in the world of children. But in order to ensure that world proceeds in it’s normal working order and in order to heal children, we sometimes have to do things to them that no normal adult would want to do. We stick IVs in them. We have to reduce fractures. I remember having to be part of a team that gowned up in full isolation gear to hold down a child who was a new onset leukemic. She needed a middle of the night procedure in an emergent medical situation. It was terriflying for her and for us. I remember seeing her family just by chance two years later during my final year of residency. It was one of her last visits in the outpatient heme-onc clinic. I had been the admitting intern when she was diagnosed, and just happened to be there to share their joy during one of their last visits. I chatted with her famiy and we relived that night. That was also one of those moments where I remember thinking, this is the right time right place.
And yesterday evening my last patient was during our new Pediatric After Hours Clinic at 530pm. It’s a shift of an entire new scheduling system that I helped designed because it makes much more sense to stagger everyone to work at 11-8pm, rather than longer 10-hour or 12-hour shifts and paying everyone overtime. Many in our department were getting burned out. Doctors were tired. Patients would complain. Parents wanted to be seen at dinner time and not bedtime. Pediatricians now prize family time over more money. There is less overtime pay, but how much money do you really need? I was seeing my last patient of my first shift of a system I helped design. I had cancelled myself for the last 2 hours because there weren’t enough patients. Good for budget and good for me. There are perks of middle management. I was going to leave at a reasonable hour at 6pm while there was still plenty of sunlight.
And last night I was standing with my last patient and her mom in the parking lot of our generic HMO outpatient building in Southern California. I was double facemasked with faceshield, standing on the sidewalk outside the concrete cookie-cutter building that I’ve been practicing for twelve years. I happened to be working my one late evening shift a month when one of my teen patients needed to be seen. Those early years of my pediatric training had been in the dramatic setting of the marbeled halls of one of the most historic hospitals in the country, where the patients were colorful characters with regional Boston accents framed in a background of the autumn leaves of New England. And last evening our backdrop was asphalt parking lot and concrete sidewalks. The temperature is always a perfect 70 degrees and there is a never changing drabness of southern california suburbia. I looked into the eyes of this teen and her mom, and we chatted.
I have cared for her since elementary school. Now COVID-19 has exacerbated her underlying emotions and she has a new onset eating disorder. She had watched a video about the dangers of sugar that set everything in motion. I walked her out to her car and her mom, because her mom wasn’t sure if she would be allowed in the building due to social distancing rules. We have a workflow and I followed the workflow. Specialty follow up was already set up for early next week. She was scared. Mother was scared. I am scared because eating disorders terrify me. But I looked at them and I saw the the little girl I met 8 years ago with her flowery top and summer hair. I saw the tween that has fallen off her bike and came in for minor injuries. I saw the cascade of images of her through the years, always on time for her well child visits and those sick visits for asthma and allergies. I saw the smiling faces of her mom and dad, who always like a good joke and know where the best chicken pot pie shop is. All those visits and memories of them and me, me and them. And I asked them, “Do you want me to call you this weekend?” They said they would be okay. They seem relieved just to be talking the three of us together. I said, “Some moments are meant to be. I’m glad we just happened to be here together tonight. I think you are going to be okay because you three love eachother so much. Just see the eating disorder team with an open heart. I know it sounds very hokey, but I think hokey works these days.” The mom gets me and I get her. We gave eachother virtual hugs.
And I turned away to walk back to clinic because I forgot that I still had one more patient I had added on. Mother and daughter turned to go. I am scared for them as new onset eating disorders terrify me, which is why I want to follow her carefully. But yesterday was one of those moments, right time right place.