July 2007

Juvenile Hall

Every once in a while, one finds oneself in Juvenile Hall.

Well not everybody, but I did, as I spent the past week in the Santa Clara County Juvenile Hall. I have to admit, at first I was more than a bit apprehensive. Growing up in the mean streets of Sugar Land, Texas I never met anybody that was in a gang, and the closest run-in I ever had with the law was the one time in high school that I got pulled over for running a red light because I was in a rush to get my tennis rackets strung for a tournament that weekend. Not the sexiest rap sheet I know.

Entering Juvenile Hall, I went through two locked doors and followed a yellow line to the control desk where they pointed me to the medical clinic. I couldn't help but feel a bit like Dorothy, or more aptly, the Cowardly Lion on the way to meet the Wizard of Oz. In this case, the Wizard of Oz turned out to be Dr. Jerry Klein, who definitely showed no penchant for smoke and mirrors and arriving and departing via hot air balloon. Immediately, he set me to work.

As part of the medical care at Juvenile Hall, each kid that comes in undergoes a full physical. The first patient I interviewed was in because he was riding in his cousins car, and when they were pulled over for a routine traffic violation, the police discovered drug paraphernalia (mushrooms and scales) in the car. An important part of the adolescent physical exam is the HEADS assessment (Home, Education, Activity, Drugs, Sex). After hearing his story, Dr. Klein came in and I presented the patient to him, and then I had the enviable job of checking for inguinal hernias. Cough, cough.

This past week has been an amazingly enlightening experience. I never for once felt unsafe at juvenile hall, and all my apprehensions quickly dissipated each day as I was greeted by the friendly nurses, medical assistants, and clerks each morning. Speaking with the patients, my eyes were opened to life in its grittiest details. At the end of the day, I realized that despite whatever crime that these kids were accused of, they were just that--kids. The toughest gang member would suddenly become the 14 year-old kid that he was when we took out a needle for a TDap vaccination.

Some of the kids were from average families who just were at the wrong place at the wrong time, but a significant majority of the kids came from group homes, children shelters, or foster homes. One young 12 year-old boy had bounced from group home to group home for months. Many were suspended from public schools and had to go to alternative independent or remedial schools, and while, most of my kids answered that PE was their favorite class, I was delighted when the rare kid would answer history (I was a history major in college) or chemistry.

Of course, often times I felt I had trouble connecting with my patients. I had never been in a gang, never heard of a group home until this week, but what I had been was a kid. And remembering what it was like to be an awkward 14 year-old (some might say I'm still awkward, but I beg to differ), scared, and away from home helped me gain at least some measure of understanding of what my patients were going through.

Most importantly, I was there to listen and learn. The beauty of providing medical care at Juvenile Hall is that the kids have no place to go. Your patients in an outpatient private practice may have soccer practice to go to or a date that night, but my kids had no other place to go but sit there and bear with my (I'm sure) boring and seemingly irrelevant questions.

I also learned quite a deal about gangs in the San Jose area. Bloods, crypts, Nortenos (Northerners), and Surenos (Southerners). One of my patients even suggested that if I were in a gang I would most likely be a Crypt--apparently its the Asian gang.

I wasn't alone in all of this. Along the way Dr. Klein encouraged me to explore these social issues, and he always made sure to call me over when he saw some pathology in a patient that he was examining in the other room.

One patient stood out for me. Joe (I changed his name) had run away from his group home, and in the process of jumping over a dry creek bed, ended up dislocating his knee. The knee joint is a fairly strong joint, and you need incredible force to completely dislocate it, tearing the ACL, PCL, MCL, LCL. When I first met Joe he was in the back of the infirmary of the clinic, a small quiet room away from the hustle and bustle of the clinic. I felt I was entering a solitary confinement room. Joe had all sorts of orthopedic hardware sticking out of his leg, a rather dramatic sight for the uninitiated like myself.

Over the course of the week, I got to know Joe. He had been in Juvie previously for hitting his father with a tequila bottle, and ran away from the group home because another kid and him would get into arguments over who got to use the phone. He also told me of his history of what sounded to me like schizophrenia. When I had down time, I would sit down next to him in his bed (inevitably waking him up from a nap), and just shoot the breeze. He told me about his faith and pointed out his favorite passages in the Book of Mormon. He told me about his desire to get back to his unit and be with his friends. And he got up excitedly and smiled each time he heard me entering his room. He asked how tall I was, and asked me to guess how tall he was. We talked about basketball. And each time as I left he would shake my hand, and I felt that for a split second I wasn't a medical student seeing a patient, but a friend visiting someone at the hospital.

That feeling raised an ambivalence within me. Could I be friends with somebody charged with assault and battery? Unfortunately, I don't know what happened with most of the kids I saw this past week, whether their cases were thrown out or they were sentenced for longer stays at Juvenile Hall or the California Youth Authority. Some were in for minor crimes, some were in for armed robbery or grand theft auto, but not once did I consider them criminals. I am not in the legal profession with their black and whites, right and wrongs. Luckily, I am in medicine, where we have the luxury of not having to view people as good or bad, but only as sick or healthy. For all they did, didn't do, or were accused of doing, the kids at Juvie were just kids, my kids, my patients, for one inspiring week.

Baptism by Fire

I started my first day of my third year of medical today, and it also marked the beginning of my clinical clerkships.

My first rotation is pediatrics, with one month of outpatient pediatrics at Santa Clara Valley Hospital and one month of inpatient pediatrics at Packard Hospital. The day started off with a nice orientation in the peds offices at Stanford. We had to say one unique thing about ourselves, and since I was the first to go and couldn't think of anything clever, I blurted out that I had a newt. And then I had to explain why I own a newt, and that I had to feed the newt live worms until I persuaded the critter to eat pellets, and altogether, it was way too much information. So now my colleagues all think I'm a herpetologist freak. Great.

After the orientation in the morning, we went off to our sites. After a brief (i.e. 5 minute) orientation at the Valley, they told us to go grab a patient and get the day started. Two of the other students had already gone through clerkships, so they actually knew how to see patients and properly interview them. My classmate and I looked at each other with fear in our eyes. This was our first hour of our first day of our first month of our first clerkship ever. We had no idea what to do.

In fact, I kind of just froze up. After only interacting with board review books, the computer interface of Kaplan Qbank, and my trusty thermos of tea for the last several months, I think I've completely lost whatever minimal social skills I had before I started studying for boards. I had no idea how to talk to normal people anymore, much less crying and sick five year-olds and their anguished parents. Luckily, the attendings sensed the fear in the air, and we ended up spending the next hour shadowing the attendings.

But the halcyon days ended quickly, and we were gently told to leave the nurturing nest and to test out our wings. I grabbed the first chart on the list, and I saw that my patient was a 5 day old baby girl here for just a weight check.

I figured that I could handle this. Weighing a baby isn't too hard. I jauntily stepped into the room with all the naivety of a fresh-faced third year medical student. I greated the family (mom, dad, two brothers), and pulled out my arsenal of pediatrics pleasantries that I had watched on the training video the night before (apparently, Tickle-Me-Elmo is the way to go, little kids love Elmo and always stop crying when they see the fuzzy head peaking out of a white coat packet). Of course, the five day old baby paid me no attention whatsoever. I asked what I could ask about bowel movements, feeding habits, etc of the baby, but really, I ran out of questions after about 46 seconds. I then smiled awkwardly and asked the parents if they had any questions--my favorite stalling tactic.

Since the chart said the reason for the visit was to weigh the baby, I figured that I could manage that. So Daddy and I plopped the baby unto the scale, and with lots of hums and hmms and all the gravitas I could muster I recorded the weight of the baby.

I thought my job was done. I went to my attending with confidence that I weighed the baby in an irreproachable manner. What ensued was a hour-long teaching session of all the things I should have done. Apparently, they were concerned about the baby's bilirubin levels, and I had to go back and track all the bili levels and then plot it on the Bhutani curve. And then I had to calculate the change in body weight from birth to discharge to today and figure out if the baby was gaining enough weight. And then I had to figure out if the mother was making enough milk. What I thought of as simply measuring the weight of the baby became an all encompassing check-up of the baby. Luckily, the attending was extremely patient, and took an hour out of her busy day to walk me through the proper management of a baby who wasn't gaining weight and the proper monitoring of bilirubin.

The most confusing part of this initial patient encounter of mine was right when I first walked in at the beginning of the H&P, the parents informed me that the baby's belly button had fallen off. I thought I misheard them and asked them to repeat it, and sure enough, they said the baby's belly button just fell off. Incredulous, I inched closer to the baby and with a sigh of relief pointed to the very much present belly button on the baby, and continued on with my merry H&P.

As I was about to step out, the parents held out a little black nubbin in their palm. And then it clicked! That was the belly button they were talking about! I sort of freaked out. In all my years of schooling, it never occurred to me that the little stump of the umbilical cord falls off a few days after birth, leaving behind the belly button! In my pristine understanding of the world, I thought babies emerged with cute little belly buttons.

So I rushed to my attending screaming, "The belly button fell off, the belly button fell off!" She looked at me, shook her head, and I thought I heard an audible sigh.

That concludes my first day of my pediatrics rotation. It is remarkable how much I learned this afternoon. I'm looking forward to the rest of the rotation. Next week, I'm heading to juvenile hall to rotate through the clinic there. Don't lose your belly buttons.