On your island (Pediatrics)

[Perrotfish]

So we're beginning to select electives for Peds, and as someone planning to go do at least a few years at a remote duty station before fellowsihp (Guam/Japan/Gitmo), what kinds of electives do you guys think could be useful? Do you think I need to be comfortable with sedation? Do you think an extra PICU and/or ER month is helpful to feel safe around emergencies? Do I need to know how/when to prescribe accutane or is that still someone elses responsibility? Is there anything else you guys would recomend knowing?

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[J-Rad]

I am currently practicing peds in an austere environment. I am constantly using critical care skills. Navy Peds is quite good with primary care so I think you'll be solid on that front. I don't think a little extra time in the unit or doing peds ED would hurt. Being able to stabilize and manage a critically ill kid until transport is available is going to be one of the biggest challenges you'll face. I constantly regret that I didn't spend more time getting facile with placing standard IVs as well (I can do them, just not great at them) so spending some time in areas where that opportunity is available wouldn't be bad.

BTW, it's been a while since somebody asked me about what I'd do "on my island"/ Thanks for the memory trip

 

[MTGas2B]

I constantly regret that I didn't spend more time getting facile with placing standard IVs as well (I can do them, just not great at them) so spending some time in areas where that opportunity is available wouldn't be bad.

Spend time with me and my peeps and jump on every IV opportunity you get. Lot's of opportunity to practice.

 

[Homunculus]

So we're beginning to select electives for Peds, and as someone planning to go do at least a few years at a remote duty station before fellowsihp (Guam/Japan/Gitmo), what kinds of electives do you guys think could be useful? Do you think I need to be comfortable with sedation? Do you think an extra PICU and/or ER month is helpful to feel safe around emergencies? Do I need to know how/when to prescribe accutane or is that still someone elses responsibility? Is there anything else you guys would recomend knowing?

brush up on those things that other people can't do. which in the world of kids is often quite a bit. things i felt gave the most bang for the buck:

nursery. this will be the bane of your existence. know murmurs, sick babies, prostin (for god's sake make sure your unit has some that isn't expired and isn't oral), circs, access (UVC/IV/Art stick), basic vent settings (if you even have one) and get NRP instructor qualified. chorio babies will hone your IV skills. congenital heart disease babies will hone your rectal tone.

clinic. know how to recognize/stabilize emergencies (asthma, seizure, sepsis, anaphylaxis, etc) to a point where they are transferable. get PALS instructor qualified. learn how to teach nurses.

PICU/NICU is probably overkill-- you aren't going to be managing these kids, you are going to be crapping your pants, trying to stabilize them and get them the heck out of your facility. a busy nursery month, a good urgent care/ER month, and getting the training is what i would recommend.

hope that helps. if anything else comes to mind i will let you know, but those are the big ones.

-- your friendly neighborhood circumcising intubating resuscitating caveman

 

[bobbyseal]

-- your friendly neighborhood circumcising intubating resuscitating caveman

If you're going to do circs on an "island" make sure you "feel comfortable" putting a 5-O chromic in the frenulum if it starts to bleed. It's so annoying to have pediatricians be okay with lopping off foreskin, but the minute it comes to managing a complication, they are suddenly uncomfortable with that.

Sorry, Homunculus...I don't mean to group you with those folks, but I found that to be so irritating as both a resident and staff.

 

[rotatores]

If you're going to do circs on an "island" make sure you "feel comfortable" putting a 5-O chromic in the frenulum if it starts to bleed. It's so annoying to have pediatricians be okay with lopping off foreskin, but the minute it comes to managing a complication, they are suddenly uncomfortable with that.

Sorry, Homunculus...I don't mean to group you with those folks, but I found that to be so irritating as both a resident and staff.

Not sure if I agree with you on this...and in fact, I'm guessing >95% of pediatricians do not feel comfortable doing this. By your reasoning would you also frown on an Ob/Gyn doing any pelvic surgery if they were not comfortable repairing the ureter they accidentally cut?

Speaking of circs...I WOULD recommend learning how to use both the Mogen and Gomco as not all commands/"islands" will have both.

Totally agree with J-rad about getting IVs. Nothing was more embarrassing as a new staff and being called in the middle of the night to get an IV to only fail miserably. Even now as a NICU fellow with fantastic nurses I put in all my IVs (or at least attempt).

 

[bobbyseal]

Not sure if I agree with you on this...and in fact, I'm guessing >95% of pediatricians do not feel comfortable doing this. By your reasoning would you also frown on an Ob/Gyn doing any pelvic surgery if they were not comfortable repairing the ureter they accidentally cut?

Speaking of circs...I WOULD recommend learning how to use both the Mogen and Gomco as not all commands/"islands" will have both.

Totally agree with J-rad about getting IVs. Nothing was more embarrassing as a new staff and being called in the middle of the night to get an IV to only fail miserably. Even now as a NICU fellow with fantastic nurses I put in all my IVs (or at least attempt).

95% of pediatricians probably don't feel comfortable doing this which still irritates me. It's a stitch. If a kid got a laceration on his arm, I'm sure every pediatric intern working in the urgent care is excited about putting in some sutures. But, when the laceration is below the waist and
above the thighs, no one seems comfortable.

A single suture to secure a bleeding frenulum is a lot different than repairing a cut ureter. I wouldn't expect/want a gynecologist to try and reimplant a ureter. The risk level and long term sequela are much higher with the latter.

To clarify my original post, if you're going to do circs in a remote location where you don't have specialty support for complications, pick one of 3 options. 1 - Be able to manage any potential complications yourself because no one else will be able to. 2. Don't have any complications. 3. Don't do elective procedures with complications you can't manage. I think 1 and 3 are reasonable options. If one thinks they can operate without complications, might as well go to Vegas because somehow your beat the house odds.

There are a lot of riskier procedures/surgeries I did during training and would still feel comfortable doing. But, I don't have IR support at my hospital. For that matter the general surgeons don't even seem to like doing hernia repairs. So, I'm not too inclined to offer more complicated procedures where I can't reliably have someone help me out in the OR or put in a drain if needed.

 

[Homunculus]

95% of pediatricians probably don't feel comfortable doing this which still irritates me. It's a stitch. If a kid got a laceration on his arm, I'm sure every pediatric intern working in the urgent care is excited about putting in some sutures. But, when the laceration is below the waist and
above the thighs, no one seems comfortable.

A single suture to secure a bleeding frenulum is a lot different than repairing a cut ureter. I wouldn't expect/want a gynecologist to try and reimplant a ureter. The risk level and long term sequela are much higher with the latter.

To clarify my original post, if you're going to do circs in a remote location where you don't have specialty support for complications, pick one of 3 options. 1 - Be able to manage any potential complications yourself because no one else will be able to. 2. Don't have any complications. 3. Don't do elective procedures with complications you can't manage. I think 1 and 3 are reasonable options. If one thinks they can operate without complications, might as well go to Vegas because somehow your beat the house odds.

There are a lot of riskier procedures/surgeries I did during training and would still feel comfortable doing. But, I don't have IR support at my hospital. For that matter the general surgeons don't even seem to like doing hernia repairs. So, I'm not too inclined to offer more complicated procedures where I can't reliably have someone help me out in the OR or put in a drain if needed.

with my n >200 for circs, i never needed to throw a stitch for a circ. simple pressure was enough for anything i happened across. during residency, i never heard of nor witnessed any sutures being required.

broadly, i see where you are coming from and agree in principle. yes, pediatricians should know how to handle common complications from procedures before doing them-- but on the other hand, this isn't something that is trained to standard in any pediatric residency i'm aware of. i never had a "suture the frenulum" board spec. we had some topical thrombin lying around i think, but no suture. i also agree that knowing how to address complications is part of being competent in doing procedures-- but i don't think we should fault people for looking to those with more experience for help. i'd prefer that over a cowboy suturing my urethra closed (which as an aside, is it really as straightforward as a forearm lac??) plus, it's a bleeding circ. it's not like you lopped off the glans or something. it'll stop eventually.

i also agree with being comfortable with the gomco, mogen, and plastibell. my facility had to bring the mogens out of mothballs for me-- they didn't even know what they were for until i showed them, lol.

--your friendly neighborhood "just hold some pressure there for 10 minutes, i'll be back" caveman

 

[rotatores]

95% of pediatricians probably don't feel comfortable doing this which still irritates me. It's a stitch. If a kid got a laceration on his arm, I'm sure every pediatric intern working in the urgent care is excited about putting in some sutures. But, when the laceration is below the waist and
above the thighs, no one seems comfortable.

A single suture to secure a bleeding frenulum is a lot different than repairing a cut ureter. I wouldn't expect/want a gynecologist to try and reimplant a ureter. The risk level and long term sequela are much higher with the latter.

To clarify my original post, if you're going to do circs in a remote location where you don't have specialty support for complications, pick one of 3 options. 1 - Be able to manage any potential complications yourself because no one else will be able to. 2. Don't have any complications. 3. Don't do elective procedures with complications you can't manage. I think 1 and 3 are reasonable options. If one thinks they can operate without complications, might as well go to Vegas because somehow your beat the house odds.

There are a lot of riskier procedures/surgeries I did during training and would still feel comfortable doing. But, I don't have IR support at my hospital. For that matter the general surgeons don't even seem to like doing hernia repairs. So, I'm not too inclined to offer more complicated procedures where I can't reliably have someone help me out in the OR or put in a drain if needed.

Okay...I was reaching I know...however, you really DON'T want 95% of pediatricians throwing in a suture. As with the good Homunculus...In my >500 circs I've never had to place a suture, but have seen it once placed by a neo...who was later chewed out by the urologist when it only made the problem worse.

Again..this is an elective procedure which we have the added benefit of counseling the parents that there is an opportunity to have a "poor cosmetic outcome" or "bleeding" followed by their signature.

My point...just learn to hold pressure. Amazingly it works.

 

[bobbyseal]

Let me clarify a bit. I'm not saying that pediatricians shouldn't do circumcisions. Please, by all means circ all the little boys, cause I don't want to do them. When one is stateside or at a hospital with support, not a big deal to do these procedures when someone can help you out. Just think a bit before doing elective procedures about possible complications and mangement of them if you are going to do this in an "austere" environment. I hear of guys getting vasectomies done while on ship and it makes me cringe. If someone develops a scrotal hematoma and needs to get explored was it really worth it to do that sailor's vasectomy?

Homonculus - watch out for that Mogen or you could be a part of the next $4 million lawsuit for penile amputation! Sure,a forearm lac is different than a penile lac. But, I find it interesting the perception of risk involved with a lot of these procedures. We are more worried about putting an absorbable suture in the urethra, but no one seems worried about a traumatic epispadias while making a dorsal slit. The 5-O chromic is easily cut out. Sewing a traumatic epispadias back together even for a pediatric urologist would generate some increased heart rate.

 

[Perrotfish]

.Alright, reviving this thread for more ideas. I'm half way through second year and we're coming up on selection for third year electives. What I'm looking at between the two years:

1 extra PICU month (Peds cards ICU to learn congenital heart disease)
2 extra weeks of NICU night float (doubles as extra nursery time because we cover it)
a Pulm month
2 weeks endocrine
1 month ID
1 month GI
2 weeks heme onc.
I was also thinking of volunteering to spend some days with anesthesia to get some airway experience, and spending one week in outpatient surgery pre-op learning to place IVs (on adults, but what can you do). Any other thoughts? Did anyone feel like they really got a lot out of a nephrology, neurology, or child abuse month? They seemed low yield to me but I'm open to ideas. For those who deployed, is subjecting myself to a month of trauma surgery and/or burn ICU good preparation or just masochism? Should I try to get an extra two weeks of normal newborn nursery? Would an extra month of Peds EM add much? Is poison control a reliable resource overseas or should I be investing in a tox elective? We do very few baby IVs/art sticks but I don't know what to do about that. Maybe a transport elective? Any other thoughts? Oh, BTW, someone please reassure me that Gyn is not a normal part of pediatrics in the fleet, because the thought of doing an elective in that makes me very depressed

Its weird, this training feels like it goes on for f-ing ever but I also feel like its not long enough. I could easily do another 6 months of electives I could do before heading out to the fleet in addition to the three years we already have.

 

[155HE]

.Alright, reviving this thread for more ideas. I'm half way through second year and we're coming up on selection for third year electives. What I'm looking at between the two years:

1 extra PICU month (Peds cards ICU to learn congenital heart disease)
2 extra weeks of NICU night float (doubles as extra nursery time because we cover it)
a Pulm month
2 weeks endocrine
1 month ID
1 month GI
2 weeks heme onc.
I was also thinking of volunteering to spend some days with anesthesia to get some airway experience, and spending one week in outpatient surgery pre-op learning to place IVs (on adults, but what can you do). Any other thoughts? Did anyone feel like they really got a lot out of a nephrology, neurology, or child abuse month? They seemed low yield to me but I'm open to ideas. For those who deployed, is subjecting myself to a month of trauma surgery and/or burn ICU good preparation or just masochism? Should I try to get an extra two weeks of normal newborn nursery? Would an extra month of Peds EM add much? Is poison control a reliable resource overseas or should I be investing in a tox elective? We do very few baby IVs/art sticks but I don't know what to do about that. Maybe a transport elective? Any other thoughts? Oh, BTW, someone please reassure me that Gyn is not a normal part of pediatrics in the fleet, because the thought of doing an elective in that makes me very depressed

Its weird, this training feels like it goes on for f-ing ever but I also feel like its not long enough. I could easily do another 6 months of electives I could do before heading out to the fleet in addition to the three years we already have.

So we're beginning to select electives for Peds, and as someone planning to go do at least a few years at a remote duty station before fellowsihp (Guam/Japan/Gitmo), what kinds of electives do you guys think could be useful? Do you think I need to be comfortable with sedation? Do you think an extra PICU and/or ER month is helpful to feel safe around emergencies? Do I need to know how/when to prescribe accutane or is that still someone elses responsibility? Is there anything else you guys would recomend knowing?

OK...a different perspective.

Not a pediatrician, but I am a parent who spent a tour in Okinawa. As a "consumer" of your skills (I plan to go back to Asia sometime after finishing residency), perhaps I can offer a different perspective. Obviously, you need to have solid primary care skills. I think that you would do yourself no wrong if you honed your emergency and nursery skills. NH Okinawa is a baby factory, and with all the babies produced on-island, statistically there is a high incidence of pathology that could be easily missed in the early neonatal period if someone didn't have a lot of experience. Second, the ER in Okinawa was staffed by a handful of ER docs, FPs, and a GMO. I knew a bunch of the ER doctors and can say that they didn't have a ton of Peds expertise, just the requisite experience they had in their residencies. Your critical care/ER skills will go a long way. There are some 20-30,000 military personnel in Okinawa--do the math to calculate the number of kids in your population. There is quite a lot of peds trauma/emergencies that occurred, and being able to be comfortable in these will serve you and your patients well. Finally, remember that you don't really have peds subspecialists overseas, at least not in Oki. The tertiary referral center for Okinawa was Tripler, so MEDEVACs were frequent. While the overseas screening process made sure that a lot of kids who needed subspecialty care didn't come over, it didn't weed out everyone. It's impossible to be an expert in everything, this is why I'd emphasize having good primary care skills again. Oh--one last thing--base housing in Okinawa had something of a mold problem...lots of allergy/asthma complaints (also among adults and my Marines). Hope this helps. For what it's worth, I was very impressed with the pediatricians who took care of my kids in Okinawa, both in clinic and in the nursery when my son was born. Be prepared to work hard--you'll be busy!!