Day 7: Children's Hospital PT and OT

Shelves, closets, even drawers full of toys, silly putty, bikes, PLUS really nice doctors... The Physical Therapy and Occupational Therapy Department at Children's Hospital was kid heaven. Again, I was struck by the importance of this kind of rehabilitation, where the muscles and the brain need to be taught to work together. This department was very special, because it did so through play.


The first patient I saw was a little Asian boy (probably around 4 years old) who had had a stroke when he was baby and had lost some of the function on the left side of his body. He was being taught to use his left hand to hold on to things again. The simplest of tasks were difficult for him to do, and he relied heavily on his right hand for everything. But the doctor brought out the toys and made him use his left hand to play. Although he was a little testy, he started using his left hand, and began "pinching" things between his thumb and index finger in order to hold them. His favorite and most difficult activity was playing with rubber toys in water. The way they got him to pinch was to allow him to fill the toys up with water with his right hand, but ask him to squirt the water out with his left. In order for the water to come out, he had to apply force, which he didn't have quite yet, but he was getting more comfortable using his hand (which the doctor told me a year ago he wouldn't use AT ALL).


Another patient I saw was this charming little 16 month old toddler who had severe low muscle tone (his muscles were very weak). The doctor told me the aim was to get him to stand on his own for about 4-5 seconds, which he did very well. Again, this was done while playing. His toys were put on a little bench, which forced him to prop himself up and keep his balance using his legs muscles. I noticed he was very, very good at crawling, and the doctor told me that was a very big improvement, because normally kids with such weak muscles tend to just slide on their butts to get to where they need to. But this strong little baby (who also had some vertebrae missing in his neck) didn't let anything stop him. He propped himself up, spun around, sat down to rest, stumbled to his mama, and played for about 45 minutes. And when it was time to go he flopped his wrist up and down and flashed a huge smile to say goodbye.


I really liked being in Children's simply because I loved interacting with kids. It was amazing to learn how much the children had improved and how much the therapy was helping with their day-to-day lives. It was also very inspiring to see these children with such wonderful personalities work through their struggles. Next time I feel like saying "I can't" ill try to remember that if these children can regain their abilities, I can also work to get better.  

Days 4, 5, and 6

5:30 pm, 8 lbs. 12.5 oz., female. 


The last time I was scheduled for labor and delivery all the women were either pre-term or postpartum. I was sent home having seen only the circumcision of a little 2 day old baby boy. Then, on Tuesday I was scheduled to be in urology. Although I saw pictures of prolapsed uterus, I didn't get to see any in person. There were only two patients being seen, and neither of them had any serious complications (although I did get to see an elderly woman's bladder and a biopsy of the inside of her labia minora, and another woman who had mild prolapse). 
I was beginning to think I had a calming aura... 


My 12 hours of labor and delivery were rescheduled for today (Wednesday). I showed up at tufts medical, second floor in Proger, and again, there were only pre-term mothers. Just as I was starting to feel unlucky, a woman, 40 weeks pregnant, came in to be induced. She had had 3 other pregnancies, so this baby would be delivered more easily. 


I stuck with her through almost every procedure, from inducement medicine injection, to contractions, to epidural, to cervix dilations, to water breakage, to more pressure, to delivery, to umbilical cord draining, to placenta removal. I was very impressed by the woman's ability to keep her good humor during the contractions in which she did not have an epidural to help. 
It was absolutely mind blowing to see the little head of the baby protrude more and more with each push. Soon her head was in the nurse's hand, and the shoulders were wiggled free until, finally the rest of the baby's body came smoothly out (along with some other things). Then dad then cut the umbilical cord and the baby was then taken to its own spot in the room to be cleaned and evaluated. However, there was still more going on with mom. 


The umbilical cord (containing special stem cells) was still attached to the placenta which was still in the mother. The blood was drained from the cord (much the same way blood is drawn for your arm) and then the cord was used to gently pull the placenta out. The placenta was examined to make sure there were no other part of it still in the mother, and when all was well, she was cleaned up and able to meet her newborn.


All this happened in the span of about 6 (or more) hours. Although it was a long time to sit around and wait, I was so grateful to have had a chance to see a live delivery. Because the mom's delivery went so smoothly and quickly, I was released from the hospital two hours early and was able to take a nap before starting my 8:45 capoeira class at Brookline Ballet. 

Day 3: Emergency Department

Whenever I go to the hospital, I regard the people wearing scrubs as gods, and today I finally got to be one of those people. However, I quickly realized how far from being “God” these people really are. I learned that the doctors in the Emergency Department can’t really do much for a patient that does not have a problem as obvious as broken bone or an open wound. Unless the patient is in critical condition and needs surgery, the doctor can only recommend sleep, ibuprofen, painkillers, or antibiotics. After that, the patient leaves as he or she came, in the hopes that in a couple of days his or her health will return back to normal.

In the Emergency Department I was able to see a many different patients complaining about a spectrum of different things. The smaller, more insignificant injuries came to the side of the department I was in (express waiting). Things like people having sinus infections, ear infections, coughs etc. were quickly dismissed with a recommendation of medicine and rest. Then there were some patients with broken bones. One young man came in with a fractured fifth metatarsal (a bone in the foot that attaches to the pinky toe), and another man came with a fractured bone in his leg which had happened four weeks earlier in Vietnam. Again, not much could be done for these people, since the body would do the healing on its own. One little girl came in with strange skin lesions and an abscess in the ear. The abscess was drained, and the doctors did not know the cause of her lesions so she was sent to dermatology to have it figured out. That is where her story in the Emergency Department ended. Another young man came in with a cut on his chin. He was given the necessary analgesic and then stitched up, and on he went. Another man complained about pain in his eyes due to sparks. The doctor put a dye in his eye that reacted with his cornea and where the cornea was damaged the dye would turn green instead of purple. The man did have some damage to his cornea, but he was told that the it was the fastest healing part of the body and then released. These doctors knew what they were doing, but there wasn’t really anything that they could do with these patients that their bodies would not do on their own.  

What I learned from being in the ED is that we have to take care of our bodies. It’s the only one we are going to get, and what we put in it to nourish it and what we do to it in everyday life can have a consequence that we will have to deal with for the rest of our lives. Doctors can give you medicine to lessen the pain, but the problem may never go away. Unlike the other departments I was in where the doctors specialize in their patient’s care, these doctors attend to an umbrella of problems and have to discern whether the patient needs to go into another department for special care or simply go home. They don’t know the backstory of the patients nor what will happen next.  

Day 2: Pediatrics Physical Therapy and Rehabilitation

Normally when I think of Botox I think of women (very much like those in Desperate Housewives) who want to somehow reverse the traces of time and maintain their youth. After my visit to Pediatrics Physical Therapy and Rehabilitation, I realized that Botox serves a purpose much more important than the superficial beautifying one we know of.

Firstly, what  is  Botox? It is Botulinum toxin produced by certain bacteria. This toxin blocks neuromuscular transmission through decreased acetylcholine release. In other words, it blocks the signals from brain and nerves to muscle. How could it possibly be useful to block signals to the muscles? 

Patients with Cerebral Palsy have cognitive deficits. The part of their brain that controls motor functions is damaged, and so signals that make their muscles contract are sent out unwillingly. These patients come in and have Botox injected into the nerves and muscles in their legs, arms, and even necks, to relax their muscles so that they may be more comfortable in their everyday lives. The procedure to inject the problematic nerve sending out the signals was very interesting. The doctor would first use electro-stimulation to locate the nerve or the muscle. And then he would inject the saline-Botox solution into the nerve. If he didn't get the appropriate impulse response from the nerve, he would move the needle around until he found the right spot. 

This procedure was most likely uncomfortable, if not painful. It was heartbreaking to hear the patients whimpering and seeing them flinching, but I was told that the doctor used a sedative, “Versed”, that acted as a relaxant and, in addition, made the patients forget what they had just gone through. Although the procedure seemed painful, the lifelong muscle stiffness seemed much worse. Leading a life with constant muscle spasm is much worse than the 35 second discomfort for each leg. 

It was amazing to see how long some of the patients live, a testament to how effective modern medicine has become. One patient, with muscular dystrophy, was 28 years old. A doctor explained that the reason he has to come in to see a pediatrician is because most patients do not live to be adults, so adult doctors are not specialized to treat patients like these. I was also amazed to learn that one of the patients with cerebral palsy was graduating from high school and going on to college to be a video game programmer. Although his motor skills were severely affected by his CP, his brain was completely functioning, and he had the capacity to learn and think the way a person without any deficiency could.  

Again, my second day was wonderful: I learned a lot, and laughed a lot. I learned a bit about the manifestations of the effects of extra copies of chromosomes, which I had read about in my first day at obstetrics. I was able to see a small child with a very rare disease, Edwards Syndrome, caused by an extra copy of the 18th chromosome (we normally have 2, one from mom and one from dad). The syndrome has a very low rate of survival, resulting from heart abnormalities, kidney malformations, and other internal organ disorders. However sad the disease of each patient, the doctors still had a very keen sense of humor, jesting about my having gotten into a “small community college in Cambridge” and laughing when getting kicked by a patient. It seems to me that the patients at Tufts Medical are in very good hands.  

Day 1: Obstetrics

   To the untrained eye, the black and white image that appears in an ultrasound is simply an outline of a little baby’s head, hands, body, and feet. However, after flipping through a book of obstetrics ultrasounds, the other seemingly amorphous spots on the screen became more identifiable—a stomach, kidney, heart, and gallbladder were all visible. The doctors I shadowed today, my first day at Tufts Medical, are specialists in identifying problems in fetuses. After I followed the doctor into the patient’s room, I quickly saw the outline of the baby, a heartbeat, and then a circle, within a circle, within a circle. Although most of it was black and gray, some white was visible. Not too soon after did I hear the words echogenic and cysts being thrown around. What did these things mean?


   The definition of echogenicity is the ability for something to generate or reflect sound waves, which in this case, are captured in an ultrasound. I found out that if something, like a fetus’ little kidney, is echogenic, then the image appears whiter on the ultrasound. This warns the doctor that the kidney is damaged or not functioning properly.  Other signs of a fetus having abnormalities can be determined by sampling the mother’s blood to check for a balance in hormones. I learned that the doctor can tell whether a baby is at high risk of being born with Down syndrome depending on the balance of the hormones. The baby can then be tested for Down syndrome by amniocentesis. What is amniocentesis?


   The baby develops in a sac called the placenta, which is inside a woman’s uterus. Inside the placenta is a fluid which contains an amniotic fluid rich with nutrients to help the baby grow.  As the baby develops, it actually swallows the fluid and urinates it back into the placenta, so that the amniotic fluid becomes the baby’s urine (and not water as I thought it was). The fluid actually contains fetal tissue, which is why, if extracted, can help more accurately determine if a baby has any genetic abnormalities. When a doctor performs amniocentesis, he penetrates the mother’s belly and the baby’s sac in order to obtain some of the fluid which will yield the baby’s karyotype (a “chart” of the baby’s chromosomes), and therefore uncover any genetic abnormalities. 


   These are two of the things I learned today shadowing at Tufts. The doctors were very patient with me, answering all my questions ranging from “Why would a pregnant woman bleed, and where does the blood come from?” to “If the baby’s kidney is failing and the amniotic fluid is low, why can’t some artificial fluid be injected into the sac?” to “What happens if a woman has complications but no insurance?” I definitely enjoyed walking around and seeing patients in different stages of pregnancy because the image of the baby was different every time. I am very excited to come back and see the babies outside of the womb. Overall, I had a great first day.