Yesterday I finished Pediatric Endocrine Fellowship, A Child and Two Monarch Catepillars
July 8, 2021
Yesterday I had two baby monarch catepillars that my mother-in-law mistakenly thought were pests. I came home after clinic and she said there was a slug eating up all the little plants I had asked her to grow from seeds I brought home. She had painstakenly grown those plants, and they were native milkweed from Nurse Lan’s garden. He had given me seeds. And we had just 6 little plants that were not more than 2 inches tall. Two catepillars had eaten them all up. My mother-in-law brought them for me to see, and they were floating in water. They were monarch catepillars and those milkweed plants were meant for them.
My mother-in-law did not know, and I knew how hard she had worked to grow these seeds I had brought home. We started the seeds late this season, and there are not enough for two hungry monarch catepillars. I read on the internet that sometimes zuchinnis or pumpkin or some kind of squashes will do, but to be careful of the pesticides even in “organic” squash. We had a small pumpkin, the first of the summer squash crop that is organic and grown from our own yard. So I did what the internet said, and placed them in a chopstick for the catepillars and also threw in a few of the remaining milkweed leaves. I’ll bring them into clinic if they are still alive today, and see if Nurse Lan can’t give them a home in his garden.
I’m not sure if I can save the two monarch catepillars. Next year we will do an earlier planting of the native milkweed. But yesterday I was able to save a family that is very dear to me, some added stress and also give them some peace of mind last night. Yesterday made my two-years of pediatric endocrine worth it. I feel like I graduated the fellowship that I had started fourteen years ago. I am not board certified and don’t practice pediatric endocrine, but in my heart I finished last night and graduated.
Before I came to our HMO, I had finished 10 months of pediatric endocrine clinical year, and 1 year of endocrine research. I did not finish because I had my now teen daughter prematurely. My plan had always been to have a second baby in fellowship and I got pregnant at the beginning of my fellowship clinical year. For me honestly back then, the baby was more important than the training program. I wanted another baby so much. But I intended to finish as I liked endocrine more than anything else and I was not brave enough to apply for pulmonology, which was where my interest truly were. After my reserach year at NIH, I had in total co-authored three papers in fellowship. I realize now that I had done a really good job. I had scored well on my mock endocrine boards as well for that stage in my training. When I left fellowship, my program provided wonderful letters of recommendation that helped me secure my HMO job that I currently have. I left in “good standing.” And I had secured a spot at UCSD pediatric endocrine fellowship, but at the last moment – told them I wanted to try primary care pediatrics. They paid good money. The hours were easier. There was no true call.
Twelve years later, I am secure in my career path and realize my tangential mind is more suited to general pediatrics. Honestly, it’s easier than being a specialist and you make more money. But I remember those nights as a fellow for almost a year that we were the “diabetic hotline” for new onset diabetes. Those nights when someone would come in with diabetic ketoacidosis, and the child would be very sick in the pediatric intensive care unit. Mr. Plastic Picker and I lived within walking distance of Mans Greatest Hospital, and I would leave my baby with his grandparents and walk in the dark across the steel bridge that spanned the Charles River into the back entrance at Mans Greatest Hospital and up the third floor to the PICU on Ellison 3. And as an endocrine fellow I would sit there, and watch the PICU fellow changing insulin orders and titrating fluids. We would not trust them to manage the new onset diabetics correctly. So we would sit there overlooking their shoulders, and then when change of shift came – I would have the numbers ready with the updated sodium, potassium, glucose, and the minute by minute insulin and fluids changes. I be able to report to the morning endocrine conference when exactly we added the potassium back to the IVFs. That’s how precise endocrine was. I liked that precision. I’m a numbers oriented kind of person.
But I’ve made a lot of excuses over the years, and I confess something I don’t need to ever confess. I always feel the need to tell folks, I did two years of training and authored only three papers. Why? What is wrong with my ego that I need to confess the one thing I did not finish in my scholarship and medical career? I think it’s because I’m a projects oriented kind of person and I always need closure. So I’m giving myself closure this morning.
Type 1 Diabetes Mellitus or auto-immune diabetes is really rare. As a primary care pediatrician, I’ve had a total of three new onset patients in my career. These were my own patients that I diagnosed myself. I’ve never missed it. I’ve also very quickly diagnosed ambiguous genitalia that ended up being late onset 21-hydroxylase deficiency and amgigous genitalia that ended up being gonadal dysgenesis. My first year as a primary care pediatrician, I walked into the room and saw a toddler with tanner 3 genitalia and facial hair. That one was easy. I ran right into the senior pediatric endocrinologists’ office who happened to be in the next hall way and said, “I used to be a fellow and there is something up!” That child ended up having an adrenal tumor. He was much older and had seen this only once in his career prior as well. I walked once into a pediatric urgent care visit for a teenage boy who had a sore of his penis. We used to joke around that endocrinologist don’t ever really use their stethoscope, but they cary orchidometer beads to grade the volume of the testes. With a parental chaperon in the room, I always examined the testicular volume anyway since I’m down there. For this teenage boy, I vividly remember saying it was fine and I examined his testes too and they were small for a teenage boy. I looked up and he was skinny and had glasses. He pulled up his pants (with the correct parental supervision there), and I washed my hands and pulled up his problem list on the EMR. It said learning disability. I just looked at his mother and said, “Uh, I know you came in for this penile abrasion which is totally fine. Just put vaseline on it. But can I send a karyotype? I’m pretty sure he has Klinefelters.” And he did. And I diagnosed that in a quick pediatric urgent care visit. I did the same for one young woman, who had another insurance for years. Just came in for a physical, and I counted all her cafe-au-lait spots. As an endocrine fellow you spend a lot of time in genetics and dysmorphology clinic. We rotate through connective tissue clinic, and specialty clinic for Down Syndrome. For this girl, after I saw the axillary freckling I sent her to dermatology right away and warned them likely she had Neurofibromatosis type 1 new mutation. And indeed she did.
Defintely the pediatric endocrine training came in handy those times. But last night, I feel like I completed my fellowship. Because one of my own little patients I diagnosed yesterday after a quick telephone visit with type 1 diabetes. Symptoms were just a few weeks, and we had a telephone visit. It was the last of the morning, and I told the mother who I care for so much. “It’s a skinny white kid who is drinking a lot and peeing alot. I need to rule this out.” I was done for the day. But this was in every sense of the word, my patient. I’m the one who takes care of this family and this set of parents. I added him on during the afternoon that I was not supposed to work. I don’t expect other people to do this, but for me – this is how I have to practice. It was a long afternoon for the family. Four hours of getting diagnosed after the urinalysis, glucose finger stick, and then lab drawn (there are a lot of labs) that took two attempts. A few more hours of getting the glucometer supplies, urine dip test, glucose finger stick, paging the “real” pediatric endocrinologist, delivering the news to mom and to father, and then delivering the news again. Delivering the first shot of lantus and first shot of humalog. Going over instructions and appointments for tomorrow. Talking to them. Giving them a juice box and crackers out the door just in case.
It was such an easy thing for me. I’ve did this so often. I had them text me their blood sugars through the evening and night. He went lower then I thought he should have, and I told them in confidence to give 2-3oz of apple juice. I didn’t like the dinner 106 number. I remember we used to have them in the high 100s or low 200s when we would first titrate the insulin. Every patient is different. I had mom text me the 2am number which was in the 190s which is good. But again, it was so easy for me. An extra afternoon in clinic for one patient. I just sat finishing charts, doing scheduling, dropping profanity at my computer screen at more middle management email nonsense. Last night also, it was easy for me. They texted me through the night, and I was watching Dawson’s Creek while I was texting back instructions.
And they will go and touch base with the real pediatric endocrinologist this morning. They’ll take over. But I was their fellow last night. I was my own patient’s diabetes hotline. And this little boy nestled within his loving family, is also my little boy. And I’m so grateful I was able to make his new diagosis a bit quicker and a bit easier. It is going to be such a long road for this family. Mother asked really good questions and I told them honestly that I don’t know about any of the current research. Maybe the really smart pediatric endocrinologist who finished training have developed a bionic pancreas. Maybe he’ll be like Iron Man.
And I wanted to share this story. I’m not sure if I’m going to let you know what happens to the two monarch catepillars. I want to share happiness and hope on this blog. There is so much darkness in the world, but if one chooses to be a source of light – than the world kind of gets a bit better because of us. My little patient yesterday and that family, they are shining sources of light and goodness. If you see they walk down the street, you’ll see halos over them. And I’m totally serious.