Medical dictionary

This exchange happened in the urgent care recently:


Mom: He threw up bile yesterday.

Me: (doubting face) Was it fluorescent green or grass green?

Mom: (like I was crazy) No, clear.

So, now, my hand is forced. I must do the world a service in the form of an easy-to-read medical dictionary for the masses.

I give you the most commonly misused words by parents, which often lead to either unreasonable medical workup if we take you seriously, or—more likely—us not taking anything you say seriously.

Pay attention.

Bile—the fluid made in your liver, stored in your gallbladder, and released into the small intestine to digest fats. This means if you are truly throwing up bile, things are flowing backwards. That is bad. Fortunately, it’s also rare. Also, bile is DARK GREEN. The two weeks spent dissecting the abdomen in medical school turns all your gloves and tools green. Everything is green. It looks like the Naked Green Machine drink.

This is what bile looks like

              -therefore, clear? NOT bile. Yellow? NOT bile. Ecto-cooler? NOT bile. Snot colored? NOT bile.

NOT bile.

Fever—in an infant, 100.4 rectally or higher. Generally we use this number throughout childhood and adolescence (thankfully the rectal part goes away), although I was recently made aware that our own occupational health (based on AAFP literature) considers 100 a fever in adults. Good thing I don’t treat adults.

                -therefore, 99.1? NOT a fever. Felt really hot? NOT a fever. She normally runs low but was 98.6? NOT a fever (unless you have true hypothalamic dysfunction). I gave her motrin but she was still 100? NOT a fever.

High pain tolerance—this one is a trick question. Just don’t ever say this. Unless you once broke your tibia and walked three miles to get to medical care, or gnawed off your own arm to break free of a rock slide, no one cares. Trust me.

Lethargic—this one is tough, because Merriam-Webster and I might get into a fight about the real definition. Traditionally, it can be a synonym for lazy, sluggish, listless. In medicine, and in pediatrics specifically, “lethargic” means “I think this kid has meningitis”. It means nothing moves you, not even discomfort, not even your favorite cartoon, not even me trying to look in your ears. It’s not good. Please try to be more specific in what you are describing.

                -therefore, your child is less active than normal, but is still happily watching a movie? NOT lethargic. Your child is wanting to be held, but still throws a fit when you don’t let him have his toy? NOT lethargic. Your kid “just isn’t himself”? NOT lethargic.

That’s it. Easy, right? Now you can save yourself the humiliation of all the health care providers rolling their eyes at you, save your kid unnecessary testing, and practice saying what you actually mean. You’re welcome.

Sharing stories

I mentioned in my last post the notion of Second Victim for health care providers who have experienced an adverse event. Every physician has been there. Whether as a result of something we did, or as part of the disease course, sometimes patients have bad outcomes. Those patients stick with us, their memories intruding at inopportune times, making us wish for a do-over, making us think maybe we don’t have what it takes.


There’s a certain pressure to be perfect, coupled with stakes of life and death, that make the Second Victim Syndrome almost ubiquitous among doctors. Yet we often hide our insecurities after such an event, not wanting to admit our human frailty, not wanting to be judged. Isolation can become the norm.


The training session that I went to this week for our new Peer to Peer Support Network aims to break through this isolation in the hopes of preventing some of the PTSD-like symptoms that doctors suffer after an adverse event. The program allows doctors the chance to emotionally debrief with a colleague who knows exactly how they are feeling. Sounds kind of touchy-feely, right? But it works.


As part of the training session, we each shared a story of an adverse event in a small group, and the other doctors just listened. It was incredibly therapeutic to open up and to have three faces of complete understanding looking back at me, nodding, knowing. They knew exactly what it felt like to get news of a poor outcome and have to wonder what you could have done differently, if you could have changed the course. They knew all too well that intrusive voice saying, “You’re not good enough. A better doctor would have done this right. You’re going to mess up again.” They know the panic of seeing that patient’s mom again, wondering how she remembers you. And they don’t even have to say anything, because I know they know.


As we shared our stories throughout the morning, you could see shoulders become less tense, faces become less masked, and affects become brighter. There is amazing potential for this program, and it’s exciting. It’s exciting because I think we’re accepted Second Victim Syndrome and burnout as inevitable for too long. We assume that doctors are capable of bearing these burdens silently and still being flawless. We expect the high rates of depression and suicide as a hazard of the job. But it doesn’t have to be that way.


This Peer to Peer Support Network, and others like it around the country, is changing the norms. Isolation and shame can give way to understanding and healing, just by talking about it. And that can make us better doctors, more able to learn from our mistakes, bounce back from setbacks, and not carry our work home with us.

The Second Victim

I recently had at work what we call an "adverse event". These are cases where something goes poorly, either because of an error, or just the natural progression of disease, but everyone feels it. A kid is very sick, or passes away, or is harmed in some way, and it shakes all of us out of our happy pediatric comfort zone. I obviously can't go into details, because HIPAA, but it hit home for me a concept that I wanted to share.

In 1999, when the Institute of Medicine published their famous (infamous?) "To Err is Human", detailing the widespread prevalence and effects of medical errors, a brave physician from Johns Hopkins thought to go one step further. In his sentinel paper, "Medical Error: The Second Victim", Albert Wu outlined the idea that medical errors, and all adverse patient events, harm more than just the patient and their families. He observed that "although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victim".

I can feel the cynicism rising up right now: How can doctors even compare their "suffering" to a patient death? Shouldn't they feel bad if they've done something wrong? Shouldn't we focus on the medical errors and stopping them instead of telling doctors "it's okay" after they mess up?

Those are all valid questions, and the answers to the last two are surely "yes", but that's not the whole story. Second victims have symptoms very similar to PTSD, experience higher rates of depression and burnout, and can have impaired performance due to maladaptive coping behaviors, decreased confidence, or fear of making a further mistake. I will attest that these are not theoretical; they are very real. And I think we can all agree that if we can avoid these effects, that's a win.

We are about to launch our own Peer to Peer Support Network at work to help second victims, and this experience has taught me a lot of things that I hope to carry forward..

I've learned that adverse events are going to happen, and that we all make mistakes. Let me repeat that: We all make mistakes. It just so happens that in our job, mistakes can range from forgetting to bring someone a blanket to causing a death, and that's terrifying. We make hundreds of decisions every day in a very stressful environment. We set up our systems to try to prevent as many errors as possible, but you can't remove the human element. We have to learn from our mistakes instead of letting them cripple us.

I've learned that I work with amazing people. One of the nurses I work with found out I was upset about the patient and said, without hesitation, "You know we all stand behind you because we know the kind of doctor you are." The other doctors, who had every right to critique the situation, instead offered their support and acknowledgement that our jobs are very difficult and we all have these days. It makes all the difference in the world to be able to have that support at work, which makes me excited to train as a peer supporter.

I've learned it's important to take a deep breath and remember why we do this. It can be so easy to get caught up in a busy day and miss the small details, miss the opportunities to really meet our patients where they are and be part of that encounter. Yesterday, with this fresh on my mind, I spend a few extra minutes in each room, talking to families, being thorough, not letting the 18 patients in the waiting room get to me. And I could feel it make a difference. I was a better doctor because of it. Hitting that reset button every now and then, without waiting for an adverse event, is crucial.


Finally, I've been reminded that I'm not doing this of my own accord. God called me to this profession, has given me the things I need to succeed, and can decide what to do with me from here on out. And that's okay. I don't have to be perfect, because He is. He is bigger than the adverse events, than the mistakes, than the bad outcomes. He also cares for His children and gives us the tools we need to move forward if we let Him.

Those who are healthy

Working in urgent care and emergency rooms, we see whatever walks through the door. That means whatever. It means the 64-year-old with appendicitis (yes, at the Children's ER), the 8-year-old who ran over his ankle with a motorized scooter and has severed nerves and blood vessels, and the toddler who had a black marker stain on his foot. At one in the morning. True story.

In the midst of all the real emergencies, it's so easy to become cynical towards the families bringing their kids in with marker stains (and trust me, it happens WAY more often than you would think!). It's so easy to judge parents, grandparents, foster parents who I think should know when to bring their kid in and when it's okay to watch at home. I get frustrated that after motrin, a popsicle, and a sticker, they look just peachy and ready to go home.

Then I read in the Gospel of Luke about the call of Levi, where Jesus tells the similarly judgmental Pharisees that "Those who are healthy do not need a physician, but the sick do." Can you see the 2x4 shaped mark on my head? Obviously no one wants to bring their kid to the Urgent Care at three in the morning. No one wants their kid to be crying and sick and miserable. They came because they need a physician. Even if all that physician needs to do is reassure them, give their kid a popsicle, and tell them what to expect for the next few days. Even if all that physician needs to do is check for an ear infection, eyeball a rash, or, yes, clean off the marker stain with an alcohol wipe.

And what a privilege it should be to treat those kids. What a privilege it should be to offer a little bit of hope, help, or healing. No matter what.

The last few days I've tried to remember that as I walk into my shift, to bring compassion to every patient, not just the ones who I think are sick enough to see me. After all, they wouldn't be there if they didn't need something.

Learning medicine

Last night I attended an awards banquet at the School of Medicine for physicians who volunteer as preceptors, taking on a student one half day a week for their first two years of medical school and part of their third, teaching them about clinical medicine in the real world. When the program was founded 30 years ago, most teaching was done in a university hospital, where less than 1% of those who sought medical care would eventually be treated.

I remember my Wednesday afternoons with my preceptor in medical school, me always feeling nervous beforehand, but excited to get out of the classroom and actually see patients. I left every evening grateful for the learning, but wondering how in the world would I ever know enough to practice medicine?

I remember my own student's first day, me still wondering if I knew enough--this time to teach it to someone else. And I guess it's going okay, because she nominated me for Best Pediatric Preceptor, which if you knew some of the others who were nominated, you'd know was a huge honor.

But there's a lot more than just imparting medical knowledge, and that was the takeaway for me yesterday. The best preceptors also invest in the relationship, becoming a role model for communication, empathy, integrity, balance, and perseverance. We have the opportunity to remind these students why they went into medicine, when they spend most of their days memorizing the Krebs cycle. We can show them the incredible gift it is to take care of patients. And in doing so remind ourselves of that very thing.

A doctor's tools

I like to think of myself as a minimalist when it comes to running tests and ordering medications in the urgent care. The nurses love it. My mother hates it. “You mean all you do is give them Motrin and a popsicle? That’s it?????” Yes, mom, that’s it. That’s all they need. Most pediatric disease is self-limited, either caused by a virus, or idiopathic (that wonderful term for “we don’t know what causes it”). Most pediatric injuries heal without major intervention. And so running a bunch of expensive, sometimes invasive tests that will most likely be normal seems like a waste in every sense of the word.

Plus, there’s a reason I went to 4 years of extra school and 3 years of indentured servitude residency. It’s called making a clinical diagnosis. You know, what doctors used to have to do for every patient, based on a good history and a thorough exam. They had to know how different heart murmurs sounded, because there was no same-day echocardiogram. They had to learn the signs of heart failure, because measuring brain natriuretic peptide hadn’t been discovered yet. And yes, they had to do a rectal exam on patients instead of getting xrays to diagnose constipation (which is still a more effective diagnostic tool, by the way). Call me crazy, but I like being a clinician instead of merely an interpreter of lab results and imaging. I pride myself on it most of the time. I spend a lot of time convincing parents that it’s a better way to go.

But if you want to make me doubt my clinical skills, if you want me to long for the ability to check a quick BMP or grab a chest x-ray, frankly, if you want to make me feel helpless, then take it all away. Put me in a teepee on the side of a mountain trying to tease out post-surgical abdominal pain in a teenage girl. Or on the phone with a worried friend who doesn’t want to make an unnecessary ER visit for her child. Or on the flag football field when someone goes down with a “pop” in one of his joints. My calm reassuring voice becomes laden with doubt, and I forget all of my training. Or at least that’s how it feels. At least for a moment. Then reason kicks in and I start to work through the problem, ruling badness in or out, looking for red flags, gathering as much information as I can.

The few physicians in my Wilderness First Responder course were sick of being outside the hospital, without any of our normal comforting resources (labs, radiology, even monitors) and not knowing what to do. We all needed a reminder that we are, in fact, clinicians first. We can use our eyes, our hands, and our brains instead of machines. I try to remind students of this when they rotate through the urgent care. It’s what I try to practice on a daily basis, even when I don’t have to, because it makes me a better doctor when I do have to.

And in reality, a popsicle is sometimes all the tool we need.

I kind of want to post this everywhere

I know that Urgent Care is easy. And the hours are better. And you’re busy. But there are just some things that shouldn’t be seen at Urgent Care. To avoid the frustration of multiple trips, waiting too long, leaving with no answers, or being judged based on your chief complaint (it happens; I’m not proud of it, but at least I’m honest), try to follow these rules.

1)      We do not have unlimited access to specialists, nor will the specialists see you sooner if you are in the Urgent Care. We get countless walk-ins and even referrals from doctors wanting their patients to have an echocardiogram or EEG, see the pediatric dentist, or get in sooner with their rheumatologist. It’s not going to happen. If it’s truly emergent, you may be admitted at our main campus and see those specialists within 24 hours, who will then decide on any workup/treatment. Otherwise, we have to go through the same channels your pediatrician does to get to the specialists, and the vast majority of the time, we are only consulting by phone, often with a resident, fellow, or mid-level provider. The end result is usually adding you to their growing appointment list, often months out. If you want a specialist, have your doctor call them instead.

2)      Please don’t come in with 6 months of chronic symptoms without seeing your regular doctor first. If you’ve had something going on for more than a few weeks and haven’t been able to solve the problem with Dr. Google or with multiple trips to other ERs, chances are it won’t be a quick fix for us either. Our job is to rule out bad things and get you the right follow up, often with your regular doctor. Plus, if we start a lab workup or want to order tests, your doctor won’t always be able to follow up on the results (and chances are we won’t either, since many of the labs and imaging studies come back once our shift is over). Additionally, if you don’t get better in two days and decide to come back, you will be seen by someone different, who will have no idea how you looked the first time, may have a totally different approach, or may disagree with what has already been done. It’s a lot easier to solve long-term issues with a long-term plan—namely, your own doctor who can see you through the illness and follow up on what they recommend.

3)      We are an URGENT care. We are not an “I just had a quick question” or “I didn’t want to make an appointment with his doctor” care. The following are all real complaints that have come in to our Urgent Care or ERs—ear pain for 20 minutes (no meds given at home), band-aid stuck to leg, need a refill on Prevacid (which is now over the counter, by the way), the child felt warm, grandma said he needed to be seen, was exposed to someone with a sore throat but doesn’t have any symptoms. There are nurse lines for these sorts of things. We are always happy to offer reassurance, but please don’t expect me to rush in when I have other rooms filled with asthmatics, broken bones, migraines, seizures, pneumonia, partially amputated fingers, or other things more…urgent. It’s always the people who don’t really need to be there that balk at the wait times. Imagine waiting until your pediatrician’s office opened. In two whole hours.

Some days are worse than others

This week I had to tell a mom her daughter had cancer.

It did not go well.

When the patient checked in, I thought that “Fever, cough” indicated yet another flu victim. But as I heard the story and progressed through my exam, my suspicions grew. And as I left the room to put orders in, I told the nurse, “She has leukemia.” Twenty minutes later when I had the first of the lab results back, I got a sinking feeling in the pit of my stomach knowing that I would have to break the news. The worst news. The news no parent wants to hear.

There is no way to predict how someone will respond. I expected tears. I didn’t expect what actually happened. It’s probably one of the most disconcerting things I’ve ever experienced to be the cause of that kind of reaction—screaming, fist-pounding, falling to the floor, more screaming. Top of the lungs screaming. Heart-rending screaming. Agony. I hated being the cause—even indirectly—of that level of anguish. I could do nothing to make it all okay, to make it all go away. In that moment, I was powerless.

Maybe that’s what I hate. Being helpless. At least when I’m suffering, I participate in the struggle, I have a role, I fight. But watching someone else grieve, watching someone else ache—I can’t fight her battle. It breaks me. So I pray. Because God knows what He’s doing. He holds that toddler and her mom just as He holds me. I’m trying to convince myself of that even as I type it. That I don’t have to have all the answers. I don’t have to be perfect. I have to present, and I have to be faithful. He will do the rest.

God has created me to do Him some definite service. He has committed some work to me which He has not committed to another. I have my mission. I may never know it in this life, but I shall be told it in the next. I am a link in a chain, a bond of connection between persons. He has not created me for naught. I shall do good; I shall do His work. I shall be an angel of peace, a preacher of truth in my own place, while not intending it if I do but keep His commandments. Therefore, I will trust Him, whatever I am, I can never be thrown away. If I am in sickness, my sickness may serve Him, in perplexity, my perplexity may serve Him. If I am in sorrow, my sorrow may serve Him. He does nothing in vain. He knows what He is about. He may take away my friends. He may throw me among strangers. He may make me feel desolate, make my spirits sink, hide my future from me. Still, He knows what He is about.                                       -John Cardinal Henry Newman

PSA for MIA parents

Imagine this. You finally get a vacation. With your spouse. Away from the kids. Hooray for Grandma and Grandpa! You hope they have everything they need, but really all you can think about is that king bed next to the window overlooking the beach. And sunshine. And quiet. You promise you'll check in every night...maybe.

Now imagine this. While you're gone, your slightly clumsy 4-year-old walks straight into a door, splits her head open, and gets taken to the wonderful pediatric urgent care down the road. Only they can't treat her. Because you are unreachable (darn cell reception on the beach), it's not a life-threatening emergency, and you forgot to give power of medical decision making to Grandma and Grandpa. Whoops.

This actually happened to me last week (well, I wasn't the one on vacation, obvi. I was the treating doctor). Mom and Dad were on a plane over the Atlantic and Grandma had one traumatized little girl and her restless older brother with no way to consent for medical care. Thankfully the plane landed and we got phone consent in time to get the patient the stitches she needed and home to bed, but there's an easier way.

If you are going to be out of town, unreachable, or leaving your kids in someone else's care for a prolonged period of time (in my mind, that's a couple of hours, given that you never know what kids will do), it's a good idea to give the caregivers medical power of attorney (MPOA) for your kids. Every state is different, but from what I know, here's the basics.

1. The MPOA does not ever supersede your rights as a parent, nor does it allow the temporary guardian the ability to let your child be adopted or get married (I know, we were all worried Grandma might go a little crazy, right?)
2. The MPOA is good for up to a year and allows a designated guardian the ability to make medical decisions for your children.
3. An MPOA is not necessary for emergency treatment. This qualifies as life- or limb-saving measures that any reasonable person would agree to for their children. This does not apply to cosmetic or non-emergent issues, even including facial stitches or broken bones (which can be set a few days later with good outcome).
4. The MPOA should be a signed document designating specific (named) people to care for your (named) children (include date of birth) during a specific period of time and should be signed and dated by the parent.
5. Our hospital (as far as I know) does not require a notarized form, and Kaiser's form says notary is optional, but for water-tight agreements, notary is preferred. Here is an example of the form for Colorado. Every state may have their own requirements.

So, next time you flee the madness of your offspring for sandy beaches (or if you know someone planning to do so), make sure an MPOA gets filled out so that we can take better care of all those kiddos.