Page 24 - Volume 70 Number 2
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The Principal Clinical Year 1968
By Richard E. Burney, MD
Part III: Pediatrics at the Boston Children’s
In the Principal Clinical Year (PCY), six weeks were spent on Pediatrics. My rotation at the Boston Children’s Hospital began with two weeks in the medical outpatient department in the Child Health Program during the day and in the medical emergency clinic (MECL) at night. The first night the MECL saw 50 patients. I worked up two: eczema with impetigo and otitis media, which presented as intermittent vomiting. I had no confidence in what I was doing, knowing as little about babies as I did. A classmate saw more interesting patients, one a 5-year old with migratory polyarthritis and an infant with diarrhea and dehydration requiring IV fluid therapy.
The pace of activity at Children’s was at first much, much slower than on the wards at Boston City. During that first week, I worked up a 7-year old girl with enuresis in the medical clinic and that night in the MECL 4 patients, all with symptoms of diarrhea, vomiting and fever. Three had gastroenteritis; one had otitis. I decided that I needed to look in a lot more ears before I could feel confident that I knew what I was looking at. In Nephrosis clinic I saw a 3 1⁄2-year old with nephrotic syndrome. The next day in Endocrine clinic I saw a 3-year old with salt-wasting adrenogenital syndrome. In the MECL, again, I worked up a 10-month old who had had a febrile seizure. One afternoon I visited a solo pediatrician practice in Wellesley Hills, which saw only 10 patients that afternoon, most for shots of one kind or another. That night, in emergency clinic, I saw a 5-month old with bronchiolitis, a return check for otitis media, a child with a Henoch-Schoenlein popular eruption, and one with mumps encephalitis.
This rotation is certainly totally different from the last one. At the \[Boston\] City you lived and breathed City hospital – it was your life. But at Children’s, at least so far in the OPD, you can come and go in a relaxed way, blissfully free of responsibility, and learn things to boot. MECL is actually kind of fun. I wish it weren’t so cramped and squalid.
I have to date managed by one flimsy excuse or another (made to myself) to avoid almost all the conferences, which makes life much more pleasant, to be sure. I’m not really interested at this point in how much I learn about Pediatric disease as much as I am in learning about children and the application of commons sense and intuition to situations in Pediatric practice – things which will be of long-term usefulness.
My last day in the OPD/MECL was a Sunday. I worked up six or more patients, including two with otitis media and one with serous otitis, and I examined a patient with acute labyrinthitis.
But the real excitement came last when a 2-year old boy came in lethargic and real sick. It took about 30 seconds to decide that the child had meningitis – unresponsiveness, stiff neck. I got the senior assistant
resident who let me do the LP and I knew it was a good one all the way. It felt good. The fluid was grossly cloudy with 7,000 WBC and the diagnosis was confirmed.
The cultures grew out N. meningitidis – and I went onto prophylactic Sulfa. Two days later, frighteningly, the older sister of the child came to MECL with a petechial rash and a stiff neck. Dx: meningococcemia. I think I’ll stay on the Sulfa for the full 3-day course.
Despite this scare, I don’t think it hit home that as students and physicians, we are at risk for getting the diseases we see and treat in others. During the year, a number of classmates got hepatitis A.
The next morning, I moved on to the inpatient service, where the pace quickly picked up.
The first day on Division 37 (Team B) would have done BCH justice: 6 admissions, on 3 of whom I did work-ups. The first was a transfer, a 15-year old with chronic renal failure and 4+ uremia for peritoneal dialysis. Then we got a cute little 6-year old with vertigo and high-frequency hearing loss; a hemophiliac with a sublingual bleed; two sicklers in crisis \[according to Fred Mandell, the moon was right\]; and a fascinating 2-year old with lethargy, unresponsiveness, poor muscle tone and nuchal rigidity. We weren’t really sure it was meningitis \[no fever\] until the LLP gave 2,500 WBC. The intern’s gram stained smear was interpreted by him as gm(+) diplos – I interpreted it as a lousy smear and stain and made one myself, which showed gm(-) pleomorphs, i.e., H. flu meningitis. I was right. I got home at 2:30 AM after a long day.
I have learned that you have to be a kid at heart to make it on the kid’s service. Smile is the watchword.
One of the patients I admitted was an 8-year old boy, A. S., who presented a diagnostic dilemma: 4-day history of rash, fever, vomiting and diarrhea. Not knowing what he had, we observed him in the hospital for several days. The consensus was allergic viral enterocolitis and maybe mesenteric lymphadenitis, but he was also seen by surgery because no one knew what his illness was.
Finally, because of a rising WBC, dropping Hct and increased abdominal tenderness he was explored today because the probability of an atypical ruptured appendix was too great to ignore. We found generalized inflam- mation and nothing else, which was comforting in a way, but on the other hand emphasized to me the relative brutality of surgery as a purely diagnostic procedure. It was rubbed in because I had to explain it to the tearful parents. And yet it was the proper procedure done at the appropriate time and it was diagnostic. I only hope it doesn’t complicate his recovery.
My other sick kid, Lori S., the 2-year old with H. flu meningitis, has still not shown significant improvement, though her ptosis is gone. It’s getting a little hard to keep reassuring her parents, too. And the real little ones are sometimes just like little black boxes, and it scares me.
More sick kids with dismal prognoses were admitted to the service. One was a 10-year old girl with aplastic anemia no longer responsive to androgens and steroids,
Washtenaw County Medical Society BULLETIN APRIL / MAY / JUNE 2018

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